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Jensen E, Rentzhog H, Herlitz J, Axelsson C, Lundgren P. Changes in temperature in preheated crystalloids at ambient temperatures relevant to a prehospital setting: an experimental simulation study with the application of prehospital treatment of trauma patients suffering from accidental hypothermia. BMC Emerg Med 2024; 24:59. [PMID: 38609897 PMCID: PMC11015674 DOI: 10.1186/s12873-024-00969-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Accidental hypothermia is common in all trauma patients and contributes to the lethal diamond, increasing both morbidity and mortality. In hypotensive shock, fluid resuscitation is recommended using fluids with a temperature of 37-42°, as fluid temperature can decrease the patient's body temperature. In Sweden, virtually all prehospital services use preheated fluids. The aim of the present study was to investigate how the temperature of preheated infusion fluids is affected by the ambient temperatures and flow rates relevant for prehospital emergency care. METHODS In this experimental simulation study, temperature changes in crystalloids preheated to 39 °C were evaluated. The fluid temperature changes were measured both in the infusion bag and at the patient end of the infusion system. Measurements were conducted in conditions relevant to prehospital emergency care, with ambient temperatures varying between - 4 and 28 °C and flow rates of 1000 ml/h and 6000 ml/h, through an uninsulated infusion set at a length of 175 cm. RESULTS The flow rate and ambient temperature affected the temperature in the infusion fluid both in the infusion bag and at the patient end of the system. A lower ambient temperature and lower flow rate were both associated with a greater temperature loss in the infusion fluid. CONCLUSION This study shows that both a high infusion rate and a high ambient temperature are needed if an infusion fluid preheated to 39 °C is to remain above 37 °C when it reaches the patient using a 175-cm-long uninsulated infusion set. It is apparent that the lower the ambient temperature, the higher the flow rate needs to be to limit temperature loss of the fluid.
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Affiliation(s)
| | | | - Johan Herlitz
- Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Christer Axelsson
- Centre for Prehospital Research, University of Borås, Borås, Sweden
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Lundgren
- Centre for Prehospital Research, University of Borås, Borås, Sweden
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Janko J, Bečka E, Kmeťová K, Hudecová L, Konečná B, Celec P, Bajaj-Elliott M, Pastorek M. Neutrophil extracellular traps formation and clearance is enhanced in fever and attenuated in hypothermia. Front Immunol 2023; 14:1257422. [PMID: 37849757 PMCID: PMC10577177 DOI: 10.3389/fimmu.2023.1257422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
Fever and hypothermia represent two opposite strategies for fighting systemic inflammation. Fever results in immune activation; hypothermia is associated with energy conservation. Systemic Inflammatory Response Syndrome (SIRS) remains a significant cause of mortality worldwide. SIRS can lead to a broad spectrum of clinical symptoms but importantly, patients can develop fever or hypothermia. During infection, polymorphonuclear cells (PMNs) such as neutrophils prevent pathogen dissemination through the formation of neutrophil extracellular traps (NETs) that ensnare and kill bacteria. However, when dysregulated, NETs also promote host tissue damage. Herein, we tested the hypothesis that temperature modulates NETs homeostasis in response to infection and inflammation. NETs formation was studied in response to infectious (Escherichia coli, Staphylococcus aureus) and sterile (mitochondria) agents. When compared to body temperature (37°C), NETs formation increased at 40°C; interestingly, the response was stunted at 35°C and 42°C. While CD16+ CD49d+ PMNs represent a small proportion of the neutrophil population, they formed ~45-85% of NETs irrespective of temperature. Temperature increased formyl peptide receptor 1 (FPR1) expression to a differential extent in CD16+ CD49d- vs. CD49d+ PMNSs, suggesting further complexity to neutrophil function in hypo/hyperthermic conditions. The capacity of NETs to induce Toll-like receptor 9 (TLR9)-mediated NF-κB activation was found to be temperature independent. Interestingly, NET degradation was enhanced at higher temperatures, which corresponded with greater plasma DNase activity in response to temperature increase. Collectively, our observations indicate that NETs formation and clearance are enhanced at 40°C whilst temperatures of 35°C and 42°C attenuate this response. Targeting PMN-driven immunity may represent new venues for intervention in pathological inflammation.
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Affiliation(s)
- Jakub Janko
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Emil Bečka
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Katarína Kmeťová
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Letícia Hudecová
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Barbora Konečná
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Peter Celec
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Mona Bajaj-Elliott
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Michal Pastorek
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
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Grygiel-Górniak B, Mazurkiewicz Ł. Positive antiphospholipid antibodies: observation or treatment? J Thromb Thrombolysis 2023:10.1007/s11239-023-02834-6. [PMID: 37264223 DOI: 10.1007/s11239-023-02834-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/03/2023]
Abstract
Antiphospholipid antibodies (APLAs) are primarily directed toward phospholipid-binding proteins and are responsible for thrombotic events. APLAs include anti-β2Glycoprotein I (anti-β2GPI), anticardiolipin (anti-CL) antibodies, and lupus anticoagulant. These antibodies are typical markers of antiphospholipid syndrome (APS) and are a part of its diagnostic criteria. Many data underline the presence of APLAs in other rheumatic diseases (e.g., systemic lupus erythematosus, systemic sclerosis, Sjögren's syndrome, rheumatoid arthritis and Behçet's disease). However, they are also detected in patients with cancer, infection, and neurological disorders. Furthermore, healthy individuals may be carriers of APLAs. Chronic asymptomatic APLAs presence is most common in the elderly and subjects with chronic diseases (including malignancies). Specific kinds of APLAs are considered markers of oncological progression. These antibodies occur in 6% of pregnant women (without diagnosed APS) and are related to many pregnancy complications. Of worth, various types of APLAs are reported to have different prothrombotic properties. The risk of thrombotic events in APLA-positive but clinically naïve patients raises many questions in clinical practice. This manuscript analyses various clinical situations and consequences of the APLAs' presence, particularly in patients without diagnosed APS. The prevalence, etiology, molecular background, and prothrombotic properties of numerous APLAs are broadly discussed. The new management approach in different clinical conditions and organ complications is present in the context of recent recommendations. Discussed data underlines that adequate and timely introduced thromboprophylaxis can decrease the risk of thrombus formation and prevent increased morbidity.
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Affiliation(s)
- Bogna Grygiel-Górniak
- Department of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Sciences, Fredry 10, 61-701, Poznan, Poland.
| | - Łukasz Mazurkiewicz
- Department of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Sciences, Fredry 10, 61-701, Poznan, Poland
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Vargas M, García A, Caicedo Y, Parra MW, Ordoñez CA. Damage control in the intensive care unit: what should the intensive care physician know and do? Colomb Med (Cali) 2021; 52:e4174810. [PMID: 34908625 PMCID: PMC8634272 DOI: 10.25100/cm.v52i2.4810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/13/2021] [Accepted: 06/02/2021] [Indexed: 12/03/2022] Open
Abstract
Damage control surgery has transformed the management of severely injured trauma patients. It was initially described as a three-step process that included bleeding control, abdominal cavity contamination, and resuscitation in the intensive care unit (ICU) before definitive repair of the injuries. When the patient is admitted into the ICU, the physician should identify all the physiological alterations to establish resuscitation management goals. These strategies allow an early correction of trauma-induced coagulopathy and hypoperfusion increasing the likelihood of survival. The objective of this article is to describe the physiological alterations in a severely injured trauma patient who undergo damage control surgery and to establish an adequate management approach. The physician should always be aware and correct the hypothermia, acidosis, coagulopathy and hypocalcemia presented in the severely injured trauma patients.
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Affiliation(s)
- Mónica Vargas
- Fundación Valle del Lili, Department of Intensive Care, Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad ICESI, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad ICESI, Cali, Colombia
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Bauman BD, Louiselle A, Nygaard RM, Vakayil V, Acton R, Hess D, Saltzman D, Kreykes N, Fischer G, Louie J, Segura B. Treatment of Hypothermic Cardiac Arrest in the Pediatric Drowning Victim, a Case Report, and Systematic Review. Pediatr Emerg Care 2021; 37:e653-e659. [PMID: 30702645 DOI: 10.1097/pec.0000000000001735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Drowning is the second leading cause of death in children. Extracorporeal membrane oxygenation (ECMO) has become the criterion standard therapy to resuscitate the hypothermic drowning victim in cardiac arrest. We present our own experience treating 5 children with hypothermic cardiac arrest in conjunction with a systematic review to analyze clinical features predictive of survival. METHODS Our search resulted in 55 articles. Inclusion criteria were as follows: (1) younger than 18 years, (2) ECMO therapy, and (3) drowning. Ten articles met our inclusion criteria. We included studies using both central and peripheral ECMO and salt or fresh water submersions. We compared clinical features of survivors to nonsurvivors. RESULTS A total of 29 patients from the 10 different studies met our criteria. Data analyzed included presenting cardiac rhythm, time to initiation of ECMO, submersion time, pH, potassium, lactate, duration of chest compressions, and survival. There was a significant increase in mortality for presenting rhythm of asystole and with hyperkalemia (P < 0.05). CONCLUSIONS Extracorporeal membrane oxygenation is an important resuscitation tool for the hypothermic drowning victim. Hyperkalemia and presenting cardiac rhythm correlate with survival although they are not reasons to end resuscitation. More studies are needed to compare the outcomes in using ECMO for the hypothermic drowning victim.
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Affiliation(s)
| | | | | | | | | | | | | | - Nathaniel Kreykes
- Department of Pediatric Surgery, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
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Kanani A, Sandve KO, Søreide K. Management of severe liver injuries: push, pack, pringle - and plug! Scand J Trauma Resusc Emerg Med 2021; 29:93. [PMID: 34256814 PMCID: PMC8278654 DOI: 10.1186/s13049-021-00907-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Arezo Kanani
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Knut Olav Sandve
- Department of Radiology, Interventional Radiology Unit, Stavanger University Hospital, Stavanger, Norway
- Stavanger Medical Image Laboratory, Stavanger University Hospital, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Horioka K, Tanaka H, Okaba K, Yamada S, Ishii N, Motomura A, Inoue H, Alkass K, Druid H, Yajima D. Hypothermia causes platelet activation in the human spleen. Thromb Res 2021; 205:47-55. [PMID: 34247097 DOI: 10.1016/j.thromres.2021.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/08/2021] [Accepted: 06/30/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Accidental hypothermia results in various dysfunctions in the human body. Additionally, coagulation disorder can lead to a life-threatening condition. We previously demonstrated that platelets stored in the spleen were activated and thus triggered coagulation disorder in a mouse model of hypothermia. In the present study, we wanted to investigate if this phenomenon in mice also occurs in humans as a reaction to hypothermia. METHODS We analyzed splenic tissue collected from 22 deceased subjects who have died from hypothermia. These samples were compared with 22 control cases not exposed to cold environment. We performed immunohistochemical staining for CD61 (a marker of all platelets) and CD62P (a marker of activated platelets). We also evaluated the morphology of platelets in the spleen with scanning electron microscopy. RESULTS Immunohistochemical analysis revealed no significant changes in the amounts of CD61-positive platelets between the hypothermia and control cases. However, the hypothermia cases contained abundant CD62P-positive platelets compared with those of the control cases. Immunohistochemical analysis also revealed that the activated platelets formed aggregates and adhered to splenic sinusoidal endothelial cells in the hypothermia cases. However, we observed no significant fibrin formation around the activated platelets. CONCLUSIONS Hypothermia resulted in splenic platelet activation, which may be used as a postmortem marker of hypothermia. The release of activated platelets from the spleen into to circulation upon rewarming may promote coagulation disturbances.
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Affiliation(s)
- Kie Horioka
- Department of Legal Medicine, International University of Health and Welfare, Japan; Department of Oncology-Pathology, Karolinska Institutet, Sweden.
| | - Hiroki Tanaka
- Division of Tumor Pathology, Department of Pathology, Asahikawa Medical University, Japan
| | - Keisuke Okaba
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Shinnosuke Yamada
- Department of Anatomy, International University of Health and Welfare, Japan
| | - Namiko Ishii
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Ayumi Motomura
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Hiroyuki Inoue
- Department of Legal Medicine, International University of Health and Welfare, Japan
| | - Kanar Alkass
- Department of Oncology-Pathology, Karolinska Institutet, Sweden
| | - Henrik Druid
- Department of Oncology-Pathology, Karolinska Institutet, Sweden
| | - Daisuke Yajima
- Department of Legal Medicine, International University of Health and Welfare, Japan
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8
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Wischnewski Spots and Black Oesophagus in Suspected Fatal Hypothermia in a Brown Howler Monkey (Alouatta guariba clamitans) and a Rabbit (Oryctolagus cuniculus). J Comp Pathol 2021; 186:18-22. [PMID: 34340800 DOI: 10.1016/j.jcpa.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/17/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
Fatal hypothermia represents a diagnostic challenge in veterinary pathology. Wischnewski spots (WS) and black oesophagus (BO) have been described in human cases of fatal hypothermia but rarely in animals. We now describe WS and BO in suspected fatal hypothermia in a free-ranging brown howler monkey (Alouatta guariba clamitans) and a pet rabbit (Oryctolagus cuniculus). Both animals had dark spots resembling WS on the gastric mucosa and the monkey also had BO with haematin deposition. In both cases, stress factors and relatively cold environmental conditions were present prior to death.
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9
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Thurman P. Hemostatic Strategies in Trauma. AACN Adv Crit Care 2021; 32:51-63. [PMID: 33725103 DOI: 10.4037/aacnacc2021473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Bleeding is a leading cause of early death from trauma. Consequently, effective hemostasis can improve the odds of survival after severe traumatic injury. Understanding the pathophysiology of trauma-induced coagulopathy can provide insights into effective strategies to assess and halt hemorrhage. Both physical assessment and appropriate laboratory studies are important in the diagnosis and evaluation of coagulopathy to identify the most effective mechanical and pharmacological strategies to achieve hemostasis. This article uses a case study approach to explore evidence-based techniques to evaluate hemorrhage and strategies to promote hemostasis.
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Affiliation(s)
- Paul Thurman
- Paul Thurman is Nurse-Scientist, Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Paca Pratt, 3-S-134, 110 S Paca St, Baltimore, MD 21201
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Meshkinfamfard M, Narvestad JK, Wiik Larsen J, Kanani A, Vennesland J, Reite A, Vetrhus M, Thorsen K, Søreide K. Structured and Systematic Team and Procedure Training in Severe Trauma: Going from 'Zero to Hero' for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods. World J Surg 2021; 45:1340-1348. [PMID: 33566121 PMCID: PMC8026408 DOI: 10.1007/s00268-021-05980-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 11/26/2022]
Abstract
Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care. Supplementary Information The online version contains supplementary material available at (doi:10.1007/s00268-021-05980-1).
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Affiliation(s)
- Maryam Meshkinfamfard
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
| | - Jon Kristian Narvestad
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
- Section for Traumatology, Surgical Clinic, Stavanger University Hospital, Stavanger, Norway
| | - Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
| | - Arezo Kanani
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
| | - Jørgen Vennesland
- Department of Surgery, Vascular & Thoracic Surgery Unit, Stavanger University Hospital, Stavanger, Norway
| | - Andreas Reite
- Section for Traumatology, Surgical Clinic, Stavanger University Hospital, Stavanger, Norway
- Department of Surgery, Vascular & Thoracic Surgery Unit, Stavanger University Hospital, Stavanger, Norway
| | - Morten Vetrhus
- Department of Surgery, Vascular & Thoracic Surgery Unit, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway
- Section for Traumatology, Surgical Clinic, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, 4068, Stavanger, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Khalilov RA, Khizrieva SI, Dzhafarova AM, Abdullaev VR. Respiratory Characteristics of Rat Liver Mitochondria Depend on the Duration of Moderate Hypothermia. Bull Exp Biol Med 2020; 169:29-34. [PMID: 32495174 DOI: 10.1007/s10517-020-04817-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Indexed: 12/01/2022]
Abstract
The development of pathological or compensatory-and-adaptive reactions in homoeothermic animals during various periods of hypothermia can be caused by shifts in the respiratory functions of the mitochondria. Short-term hypothermia promoted an increase in the rates of the glutamate- and succinate-dependent respiration of mitochondria. Phosphorylation rate increased as well, while oxidative phosphorylation coefficient (P/O), respiratory control, and 2,4-DNP sensitivity depended. Changes in respiratory characteristics in the dynamics of prolonged hypothermia depends on the type of substrate. Prolongation of hypothermia to 1 h was associated with further intensification of succinate-dependent respiration, decrease in P/O and respiratory control, while prolongation of hypothermia to 3 h led to their normalization. The majority of respiratory characteristics of glutamate-dependent respiration did not change under these conditions and their levels were the same as during short-term hypothermia.
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Affiliation(s)
- R A Khalilov
- Department of Biochemistry and Biophysics, Dagestan State University, Makhachkala, Dagestan Republic, Russia
| | - S I Khizrieva
- Department of Biochemistry and Biophysics, Dagestan State University, Makhachkala, Dagestan Republic, Russia
| | - A M Dzhafarova
- Department of Biochemistry and Biophysics, Dagestan State University, Makhachkala, Dagestan Republic, Russia.
| | - V R Abdullaev
- Department of Biochemistry and Biophysics, Dagestan State University, Makhachkala, Dagestan Republic, Russia
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End-tidal carbon dioxide underestimates plasma carbon dioxide during emergent trauma laparotomy leading to hypoventilation and misguided resuscitation: A Western Trauma Association Multicenter Study. J Trauma Acute Care Surg 2020; 87:1119-1124. [PMID: 31389913 DOI: 10.1097/ta.0000000000002469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND End-tidal carbon dioxide (ETCO2) is routinely used during elective surgery to monitor ventilation. The role of ETCO2 monitoring in emergent trauma operations is poorly understood. We hypothesized that ETCO2 values underestimate plasma carbon dioxide (pCO2) values during resuscitation for hemorrhagic shock. METHODS Multicenter trial was performed analyzing the correlation between ETCO2 and pCO2 levels. RESULTS Two hundred fifty-six patients resulted in 587 matched pairs of ETCO2 and pCO2. Correlation between these two values was very poor with an R of 0.04. 40.2% of patients presented to the operating room acidotic and hypercarbic with a pH less than 7.30 and a pCO2 greater than 45 mm Hg. Correlation was worse in patients that were either acidotic or hypercarbic. Forty-five percent of patients have a difference greater than 10 mm Hg between ETCO2 and pCO2. A pH less than 7.30 was predictive of an ETCO2 to pCO2 difference greater than 10 mm Hg. A difference greater than 10 mm Hg was predictive of mortality independent of confounders. CONCLUSION Nearly one half (45%) of patients were found to have an ETCO2 level greater than 10 mm Hg discordant from their PCO2 level. Reliance on the discordant values may have contributed to the 40% of patients in the operating room that were both acidotic and hypercarbic. Early blood gas analysis is warranted, and a lower early goal of ETCO2 should be considered. LEVEL OF EVIDENCE Therapeutic, level IV.
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Abstract
It must be remembered that clinically important haemostasis occurs in vivo and not in a tube, and that variables such as the number of bleeding events and bleeding volume are more robust measures of bleeding risk than the results of analyses. In this narrative review, we highlight trauma, surgery, and mild induced hypothermia as three clinically important situations in which the effects of hypothermia on haemostasis are important. In observational studies of trauma, hypothermia (body temperature <35°C) has demonstrated an association with mortality and morbidity, perhaps owing to its effect on haemostatic functions. Randomised trials have shown that hypothermia causes increased bleeding during surgery. Although causality between hypothermia and bleeding risk has not been well established, there is a clear association between hypothermia and negative outcomes in connection with trauma, surgery, and accidental hypothermia; thus, it is crucial to rewarm patients in these clinical situations without delay. Mild induced hypothermia to ≥33°C for 24 hours does not seem to be associated with either decreased total haemostasis or increased bleeding risk.
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Affiliation(s)
- Thomas Kander
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund, Sweden
| | - Ulf Schött
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund, Sweden
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Zhu X, Gui Y, Zhu B, Sun J. Anesthetic management of a patient with 10 l of blood loss during operation for a retroperitoneal mass. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2015.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Xueqin Zhu
- Department of Anesthesia, The Affiliated Hospital of School of Medicine of Ningbo University , 247 Renmin Rd. , Ningbo City, Zhejiang Province, 315020, PR China
| | - Yu Gui
- Department of Anesthesia, The Affiliated Hospital of School of Medicine of Ningbo University , 247 Renmin Rd. , Ningbo City, Zhejiang Province, 315020, PR China
| | - Binbin Zhu
- Department of Anesthesia, The Affiliated Hospital of School of Medicine of Ningbo University , 247 Renmin Rd. , Ningbo City, Zhejiang Province, 315020, PR China
| | - Jian Sun
- Department of Anesthesia, The Affiliated Hospital of School of Medicine of Ningbo University , 247 Renmin Rd. , Ningbo City, Zhejiang Province, 315020, PR China
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Traumatic injury pattern is of equal relevance as injury severity for experimental (poly)trauma modeling. Sci Rep 2019; 9:5706. [PMID: 30952899 PMCID: PMC6450898 DOI: 10.1038/s41598-019-42085-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 03/21/2019] [Indexed: 01/02/2023] Open
Abstract
This study aims to elaborate the relevance of trauma severity and traumatic injury pattern in different multiple and/or polytrauma models by comparing five singular trauma to two different polytrauma (PT) models with high and one multiple trauma (MT) model with low injury-severity score (ISS). The aim is to provide a baseline for reducing animal harm according to 3Rs by providing less injury as possible in polytrauma modeling. Mice were randomly assigned to 10 groups: controls (Ctrl; n = 15), Sham (n = 15); monotrauma groups: hemorrhagic shock (HS; n = 15), thoracic trauma (TxT; n = 18), osteotomy with external fixation (Fx; n = 16), bilateral soft tissue trauma (bSTT; n = 16) or laparotomy (Lap; n = 16); two PT groups: PT I (TxT + HS + Fx; ISS = 18; n = 18), PT II (TxT + HS + Fx + Lap; ISS = 22; n = 18), and a MT group (TxT + HS + bSTT + Lap, ISS = 13; n = 18). Activity and mortality were assessed. Blood gas analyses and organ damage markers were determined after 6 h. Significant mortality occurred in TxT, PT and MT (11.7%). Activity decreased significantly in TxT, HS, both polytrauma and MT vs. Ctrl/Sham. PT-groups and MT had significantly decreased activity vs. bsTT, Lap or Fx. MT had significantly lower pCO2vs. Ctrl/Sham, Lap or bsTT. Transaminases increased significantly in PT-groups and MT vs. Ctrl, Sham or monotrauma. Traumatic injury pattern is of comparable relevance as injury severity for experimental multiple or (poly)trauma modeling.
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Nakae R, Yokobori S, Yokota H. Coagulopathy and Brain Injury. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Stein LH, Rubinfeld G, Balsam LB, Ursomanno P, DeAnda A. Too Cold to Clot? Does Intraoperative Hypothermia Contribute to Bleeding After Aortic Surgery? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2018; 5:106-116. [PMID: 29657946 DOI: 10.12945/j.aorta.2017.16.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/12/2017] [Indexed: 11/18/2022]
Abstract
Background We determined the impact of intraoperative hypothermia on postoperative bleeding after thoracic aortic surgery. Methods We retrospectively analyzed 98 consecutive patients who underwent aortic surgery with deep hypothermic circulatory arrest between 2010 and 2014. We evaluated lowest temperature, absolute decrease in temperature, and rewarming rate. Univariate and multivariate regression were used to determine relationships between temperature, clinical characteristics, and measures of postoperative bleeding. Results The mean age of patients was 60.5 ± 15.1 years, with 64.3% male and 60% Caucasian. The lowest temperatures recorded were 13.5 ± 4.6°C at the bypass circuit. Change in hematocrit was associated with ethnicity, preoperative hematocrit, and rewarming rate. Chest tube output was associated with body mass index, preoperative platelet count, prior cardiac surgery, cardiopulmonary bypass (CPB) duration, intraoperative blood product transfusion, lowest surface temperature, and change in surface temperature. Postoperative packed red blood cell transfusion was associated with ejection fraction, chronic obstructive pulmonary disease (COPD), platelet count, partial thromboplastin time, CPB duration, and lowest blood temperature. Fresh frozen plasma transfusion correlated with COPD, CPB duration, and final blood temperature. Platelet transfusion correlated with body mass index and preoperative platelet count. Unplanned reoperation for bleeding was associated with final temperature and change in temperature. Conclusion We found no consistent associations between intraoperative temperature and indicators of bleeding. Intraoperative cooling strategies should be based on optimal end-organ protection rather than fear of postoperative bleeding; rewarming strategies may ameliorate the risk of coagulopathy.
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Affiliation(s)
- Louis H Stein
- Division of Cardiothoracic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Gregory Rubinfeld
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Leora B Balsam
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Patricia Ursomanno
- Maimonides Heart and Vascular Center, Maimonides Medical Center, Brooklyn, New York, USA
| | - Abe DeAnda
- Division of Cardiothoracic Surgery, University of Texas Medical Branch-Galveston, Galveston, Texas, USA
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Jones AR, Frazier SK. Consequences of Transfusing Blood Components in Patients With Trauma: A Conceptual Model. Crit Care Nurse 2017; 37:18-30. [PMID: 28365647 DOI: 10.4037/ccn2017965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Transfusion of blood components is often required in resuscitation of patients with major trauma. Packed red blood cells and platelets break down and undergo chemical changes during storage (known as the storage lesion) that lead to an inflammatory response once the blood components are transfused to patients. Although some evidence supports a detrimental association between transfusion and a patient's outcome, the mechanisms connecting transfusion of stored components to outcomes remain unclear. The purpose of this review is to provide critical care nurses with a conceptual model to facilitate understanding of the relationship between the storage lesion and patients' outcomes after trauma; outcomes related to trauma, hemorrhage, and blood component transfusion are grouped according to those occurring in the short-term (≤30 days) and the long-term (>30 days). Complete understanding of these clinical implications is critical for practitioners in evaluating and treating patients given transfusions after traumatic injury.
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Affiliation(s)
- Allison R Jones
- Allison R. Jones is an assistant professor, Department of Acute, Chronic, and Continuing Care, School of Nursing, University of Alabama, Birmingham, Alabama. She has a clinical background in emergency and trauma nursing. In research, she focuses on the consequences of blood component storage and transfusion, with particular interest in transfusion after trauma. .,Susan K. Frazier is the director of the PhD program, a codirector of the RICH Heart Program, and an associate professor, College of Nursing, University of Kentucky, Lexington, Kentucky. Her research focuses on cardiopulmonary interactions in a variety of critically ill patients, including patients with acute heart failure, acute decompensated heart failure, acute respiratory distress syndrome, chronic obstructive pulmonary disease, and multiple trauma.
| | - Susan K Frazier
- Allison R. Jones is an assistant professor, Department of Acute, Chronic, and Continuing Care, School of Nursing, University of Alabama, Birmingham, Alabama. She has a clinical background in emergency and trauma nursing. In research, she focuses on the consequences of blood component storage and transfusion, with particular interest in transfusion after trauma.,Susan K. Frazier is the director of the PhD program, a codirector of the RICH Heart Program, and an associate professor, College of Nursing, University of Kentucky, Lexington, Kentucky. Her research focuses on cardiopulmonary interactions in a variety of critically ill patients, including patients with acute heart failure, acute decompensated heart failure, acute respiratory distress syndrome, chronic obstructive pulmonary disease, and multiple trauma
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Denk S, Neher MD, Messerer DAC, Wiegner R, Nilsson B, Rittirsch D, Nilsson-Ekdahl K, Weckbach S, Ignatius A, Kalbitz M, Gebhard F, Weiss ME, Vogt J, Radermacher P, Köhl J, Lambris JD, Huber-Lang MS. Complement C5a Functions as a Master Switch for the pH Balance in Neutrophils Exerting Fundamental Immunometabolic Effects. THE JOURNAL OF IMMUNOLOGY 2017; 198:4846-4854. [PMID: 28490576 DOI: 10.4049/jimmunol.1700393] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/16/2017] [Indexed: 01/08/2023]
Abstract
During sepsis, excessive activation of the complement system with generation of the anaphylatoxin C5a results in profound disturbances in crucial neutrophil functions. Moreover, because neutrophil activity is highly dependent on intracellular pH (pHi), we propose a direct mechanistic link between complement activation and neutrophil pHi In this article, we demonstrate that in vitro exposure of human neutrophils to C5a significantly increased pHi by selective activation of the sodium/hydrogen exchanger. Upstream signaling of C5a-mediated intracellular alkalinization was dependent on C5aR1, intracellular calcium, protein kinase C, and calmodulin, and downstream signaling regulated the release of antibacterial myeloperoxidase and lactoferrin. Notably, the pH shift caused by C5a increased the glucose uptake and activated glycolytic flux in neutrophils, resulting in a significant release of lactate. Furthermore, C5a induced acidification of the extracellular micromilieu. In experimental murine sepsis, pHi of blood neutrophils was analogously alkalinized, which could be normalized by C5aR1 inhibition. In the clinical setting of sepsis, neutrophils from patients with septic shock likewise exhibited a significantly increased pHi These data suggest a novel role for the anaphylatoxin C5a as a master switch of the delicate pHi balance in neutrophils resulting in profound inflammatory and metabolic changes that contribute to hyperlactatemia during sepsis.
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Affiliation(s)
- Stephanie Denk
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital Ulm, 89081 Ulm, Germany
| | - Miriam D Neher
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital Ulm, 89081 Ulm, Germany
| | - David A C Messerer
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital Ulm, 89081 Ulm, Germany
| | - Rebecca Wiegner
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital Ulm, 89081 Ulm, Germany
| | - Bo Nilsson
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 751 85 Uppsala, Sweden
| | - Daniel Rittirsch
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Sebastian Weckbach
- Department of Orthopedic Surgery, Ulm University, University and Rehabilitation Clinics Ulm, 89081 Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Ulm University, 89081 Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Florian Gebhard
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Manfred E Weiss
- Department of Anesthesiology, University Hospital Ulm, 89081 Ulm, Germany
| | - Josef Vogt
- Institute of Anesthesiological Pathophysiology and Process Engineering, Ulm University, 89081 Ulm, Germany
| | - Peter Radermacher
- Institute of Anesthesiological Pathophysiology and Process Engineering, Ulm University, 89081 Ulm, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, 23538 Lübeck, Germany.,Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229; and
| | - John D Lambris
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Markus S Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital Ulm, 89081 Ulm, Germany;
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Abstract
Hypothermia, along with acidosis and coagulopathy, is part of the lethal triad that worsen the prognosis of severe trauma patients. While accidental hypothermia is easy to identify by a simple measurement, it is no less pernicious if it is not detected or treated in the initial phase of patient care. It is a multifactorial process and is a factor of mortality in severe trauma cases. The consequences of hypothermia are many: it modifies myocardial contractions and may induce arrhythmias; it contributes to trauma-induced coagulopathy; from an immunological point of view, it diminishes inflammatory response and increases the chance of pneumonia in the patient; it inhibits the elimination of anaesthetic drugs and can complicate the calculation of dosing requirements; and it leads to an over-estimation of coagulation factor activities. This review will detail the pathophysiological consequences of hypothermia, as well as the most recent principle recommendations in dealing with it.
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Affiliation(s)
- Fanny Vardon
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
| | - Ségolène Mrozek
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
| | - Thomas Geeraerts
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France.
| | - Olivier Fourcade
- Équipe d'accueil « Modélisation de l'agression tissulaire et nociceptive », Toulouse University Teaching Hospital, Université Toulouse III Paul-Sabatier, Hôpital Pierre-Paul-Riquet, CHU de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 09, France
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Lynch AM, deLaforcade AM, Meola D, Shih A, Bandt C, Guerrero NH, Riccó C. Assessment of hemostatic changes in a model of acute hemorrhage in dogs. J Vet Emerg Crit Care (San Antonio) 2016; 26:333-43. [PMID: 26890726 DOI: 10.1111/vec.12457] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 08/22/2014] [Accepted: 09/15/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate hemostatic changes following experimental acute hemorrhage in dogs using traditional coagulation tests (eg, platelet count, prothrombin time [PT], and activated partial thromboplastin time [aPTT]), kaolin-activated thromboelastography (TEG), and whole blood multiple electrode impedance platelet aggregometry. DESIGN Prospective study. SETTING Research laboratory. ANIMALS Five Beagles. INTERVENTIONS Dogs were anesthetized prior to obtaining blood samples for baseline PCV, total plasma protein (TPP), arterial blood-gas, platelet count, PT, aPTT, TEG, fibrinogen, and aggregometry. Blood was obtained at 4 additional time points, following 20% blood volume loss, 40% blood volume loss, 60 minutes of sustained hypotension, and after autologous blood transfusion. In addition, heart rate and direct arterial blood pressure were measured at each time point. MEASUREMENTS AND MAIN RESULTS Significant decreases were noted for PCV (P = 0.048), TPP (P < 0.0001), and arterial blood pressures (P < 0.0001) over time. Platelet count did not change significantly (P = 0.879), but platelet function was decreased following hemorrhage when arachidonic acid (P = 0.004) and ADP (P = 0.008) were used as agonists. The TEG variables R (P = 0.030), MA (P = 0.043), and G (P = 0.037) were significantly, albeit mildly, changed following hemorrhage. Significant prolongations in PT (P < 0.0001) and aPTT (P = 0.041), and decreases in fibrinogen concentration (P = 0.002) were also seen. CONCLUSION Platelet dysfunction occurred following hemorrhage in this model, despite a stable platelet count. Additionally, significant changes associated with hemorrhage were documented in aPTT, fibrinogen, and MA. Platelet function testing in dogs with naturally occurring hemorrhage warrants further investigation.
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Affiliation(s)
- Alex M Lynch
- Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | | | - Dawn Meola
- Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - Andre Shih
- College of Veterinary Medicine, University of Florida, Gainesville, FL
| | - Carsten Bandt
- College of Veterinary Medicine, University of Florida, Gainesville, FL
| | | | - Carolina Riccó
- Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA
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Lynch AM, O'Toole TE, Respess M. Transfusion practices for treatment of dogs hospitalized following trauma: 125 cases (2008–2013). J Am Vet Med Assoc 2015; 247:643-9. [DOI: 10.2460/javma.247.6.643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Shcherbina IA, Lipets EN, Abaeva AA, Balandina AN, Ataullakhanov FI. [Influence of temperature on spatial fibrin clot formation process in thrombodynamics]. BIOMEDIT︠S︡INSKAI︠A︡ KHIMII︠A︡ 2014; 60:493-502. [PMID: 25249534 DOI: 10.18097/pbmc20146004493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In this study we have investigated the process of spatial fibrin clot formation in non-steered platelet-free plasma at the temperatures from 20°C to 43°C using thrombodynamics - the novel in vitro hemostasis assay, which imitates the process of hemostatic clot growth in vivo. During data processing the following parameters were calculated: initial (V i ) and stationary (V st ) rates of clot growth which characterize initiation and propagation phases of clotting process, and clot size on the 30 th minute. The temperature dependence of extrinsic and intrinsic tenase activities, which determine values of the initial and stationary clot growth rates, respectively, have been also measured. It was established that the temperature lowering from 37°C to 24°C extends mainly on the initiation phase of clot growth, while the stationary rate of clot growth changes insignificantly. Meanwhile none of the thrombodynamics parameters shows the dramatic change of plasma coagulation system condition at the temperature of 24°C (acute hypothermia). Using the thrombodynamics assay an assumption, that the temperature lowering does not change the state of plasma hemostasis system significantly has been confirmed.
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Spence R, Spence R. Surgery of the troubles: lessons for the future. J Am Coll Surg 2014; 219:171-80. [PMID: 24974264 DOI: 10.1016/j.jamcollsurg.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Roy Spence
- Department of Surgery, Queen's University Belfast, Northern Ireland.
| | - Robert Spence
- Department of Surgery, Queen's University Belfast, Northern Ireland
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Cherian A, Udupi BP. Acute coagulopathy of trauma: Mechanism, monitoring, management. World J Anesthesiol 2014; 3:111-118. [DOI: 10.5313/wja.v3.i1.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/14/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
Coagulopathy is a well-known consequence of trauma and is the most common cause of mortality in the young. However, its cause and management is still controversial. A new concept in the understanding of coagulopathy in trauma is the occurrence of Acute coagulopathy of trauma (ACoT). ACoT is associated with hypo perfusion and tissue trauma as seen in massive injury. The incidence of coagulopathy increases with injury scores and is associated with higher number of ventilator days, higher morbidity and mortality. The process of coagulation is better described by the cell based model with a central role for platelets rather than the older plasma based model. This shift in our understanding supports the theory that ACoT results from the endothelial release of thrombomodulin and activated protein C in the presence of hypoperfusion. This in turn leads on to a hyperfibrinolytic and hypocoagulable state. Viscoelastic hemostatic assays are replacing the older tests like prothrombin time in the assessment of coagulopathy. These tests are accurate, determine the need for transfusion and can be performed at the point of care. Damage control resuscitation includes newer concepts like permissive hypotension, increased use of plasma as a part of massive transfusion protocols and damage control surgery.
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External validation of the Emergency Trauma Score for early prediction of mortality in trauma patients. Crit Care Med 2014; 42:83-9. [PMID: 23982027 DOI: 10.1097/ccm.0b013e31829e53f5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Emergency Trauma Score has been developed for early estimation of mortality risk in adult trauma patients with an Injury Severity Score of 16 or higher. Emergency Trauma Score combines four early predictors available at the trauma resuscitation room: age, Glasgow Coma Scale, base excess, and prothrombin time. Our goal was to validate the Emergency Trauma Score in two large external cohorts. As the Injury Severity Score is not accurately known at the time patients present at the resuscitation room, we evaluated the performance of Emergency Trauma Score in all trauma patients. DESIGN External validation study using data from two prospectively collected trauma registries. SETTING Two academic level 1 trauma centers. PATIENTS Adult patients admitted to the hospital after treatment at the trauma resuscitation room. INTERVENTION Calibration and discrimination of the original Emergency Trauma Score were assessed within each cohort separately. MEASUREMENT AND MAIN RESULTS A total of 4,418 consecutive patients were evaluated. Discrimination was good in both validation cohorts, with areas under the receiver-operating curve curves that were even higher (0.94 and 0.92, respectively) than that in the original cohort (0.83). Predicted mortality was systematically too high compared with actual mortality in patients with low-to-medium expected risk (< 25%). Calibration improved in the lower expected risk range after exclusion of patients with Injury Severity Score less than 16. CONCLUSIONS The Emergency Trauma Score model performs well in discriminating between trauma patients who will survive and who will not. If applied to all trauma patients, predicted mortality risks are too high in the low-risk category.
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Evaluation of the utility of thromboelastography in a tertiary trauma care centre. ISRN HEMATOLOGY 2014; 2014:849626. [PMID: 24695847 PMCID: PMC3947774 DOI: 10.1155/2014/849626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 12/15/2013] [Indexed: 12/05/2022]
Abstract
Background. Thromboelastography (TEG) unlike conventional coagulation assays evaluates the dynamic interaction of clotting factors and platelets indicating an overall clot quality. Literature assessing the efficacy of TEG in identifying trauma associated bleeding is lacking. Aim. To compare TEG with conventional plasma based coagulation tests and assess whether TEG can serve as a screening test or replace the conventional routine test. Materials. Retrospective data was collected for 150 severe trauma patients. Patients with known evidence of severe comorbidities, which may influence the outcome, were excluded. Detailed evaluation of the patient's clinical and laboratory records was conducted. Diagnostic characteristics such as sensitivity, specificity, and accuracy were calculated. Results. Fifty-one patients were defined as coagulopathic by the conventional coagulation test, 30 by the laboratory established range for TEG indices and 105 by manufactures range. Specificity and sensitivity for the laboratory established range for TEG were 29.4% and 84.8%; for manufactures range sensitivity was 74.5%, specificity was 32.3%. Conclusion. We observed that conventional coagulation assays are the most sensitive tests for diagnosis of coagulopathy due to trauma. However in emergency trauma situations, where immediate corrective measures need to be taken, coagulation parameters and conventional coagulation tests may cause delay. TEG can give highly specific results depicting the underlying coagulopathy.
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Warming with an underbody warming system reduces intraoperative hypothermia in patients undergoing laparoscopic gastrointestinal surgery: A randomized controlled study. Int J Nurs Stud 2014; 51:181-9. [DOI: 10.1016/j.ijnurstu.2013.05.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 05/20/2013] [Accepted: 05/20/2013] [Indexed: 02/06/2023]
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The pathophysiology, diagnosis and treatment of the acute coagulopathy of trauma and shock: a literature review. Eur J Trauma Emerg Surg 2013; 41:259-72. [DOI: 10.1007/s00068-013-0360-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 12/01/2013] [Indexed: 10/25/2022]
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Abstract
Although, historically, shock associated with traumatic injury has been evaluated through knowledge of the 4 recognized shock patterns--cardiogenic, obstructive, distributive, and hypovolemic--many trauma practitioners view traumatic shock as a unique fifth shock pattern. Although secondary to a systemic inflammatory response syndrome triggered by endogenous danger signals, traumatic shock represents a unique pathological condition that begins with multiple, usually blunt, trauma and may conclude with multiple organ dysfunction syndrome and death. While varying mechanisms of injury may lead to different presentations of shock and cardiovascular decompensation, a unifying theme of traumatic shock is an overwhelming inflammatory response driven by proinflammatory cytokines, and the downstream results of this cytokine storm including, but not limited to, acute respiratory distress syndrome, coagulopathy, sepsis, and multiple organ dysfunction syndrome. Treatment is primarily supportive; however, research into novel therapeutics for traumatic shock is ongoing and promises some direction for future care.
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Oxidative stress and antioxidant activity in hypothermia and rewarming: can RONS modulate the beneficial effects of therapeutic hypothermia? OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2013; 2013:957054. [PMID: 24363826 PMCID: PMC3865646 DOI: 10.1155/2013/957054] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 10/21/2013] [Indexed: 12/12/2022]
Abstract
Hypothermia is a condition in which core temperature drops below the level necessary to maintain bodily functions. The decrease in temperature may disrupt some physiological systems of the body, including alterations in microcirculation and reduction of oxygen supply to tissues. The lack of oxygen can induce the generation of reactive oxygen and nitrogen free radicals (RONS), followed by oxidative stress, and finally, apoptosis and/or necrosis. Furthermore, since the hypothermia is inevitably followed by a rewarming process, we should also consider its effects. Despite hypothermia and rewarming inducing injury, many benefits of hypothermia have been demonstrated when used to preserve brain, cardiac, hepatic, and intestinal function against ischemic injury. This review gives an overview of the effects of hypothermia and rewarming on the oxidant/antioxidant balance and provides hypothesis for the role of reactive oxygen species in therapeutic hypothermia.
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Computational analysis of the effects of reduced temperature on thrombin generation: the contributions of hypothermia to coagulopathy. Anesth Analg 2013; 117:565-574. [PMID: 23868891 DOI: 10.1213/ane.0b013e31829c3b22] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hypothermia, which can result from tissue hypoperfusion, body exposure, and transfusion of cold resuscitation fluids, is a major factor contributing to coagulopathy of trauma and surgery. Despite considerable efforts, the mechanisms of hypothermia-induced blood coagulation impairment have not been fully understood. We introduce a kinetic modeling approach to investigate the effects of hypothermia on thrombin generation. METHODS We extended a validated computational model to predict and analyze the impact of low temperatures (with or without concomitant blood dilution) on thrombin generation and its quantitative parameters. The computational model reflects the existing knowledge about the mechanistic details of thrombin generation biochemistry. We performed the analysis for an "average" subject, as well as for 472 subjects in the control group of the Leiden Thrombophilia Study. RESULTS We computed and analyzed thousands of kinetic curves characterizing the generation of thrombin and the formation of the thrombin-antithrombin complex (TAT). In all simulations, hypothermia in the temperature interval 31°C to 36°C progressively slowed down thrombin generation, as reflected by clotting time, thrombin peak time, and prothrombin time, which increased in all subjects (P < 10(-5)). Maximum slope of the thrombin curve was progressively decreased, and the area under the thrombin curve was increased in hypothermia (P < 10(-5)); thrombin peak height remained practically unaffected. TAT formation was noticeably delayed (P < 10(-5)), but the final TAT levels were not significantly affected. Hypothermia-induced fold changes in the affected thrombin generation parameters were larger for lower temperatures, but were practically independent of the parameter itself and of the subjects' clotting factor composition, despite substantial variability in the subject group. Hypothermia and blood dilution acted additively on the thrombin generation parameters. CONCLUSIONS We developed a general computational strategy that can be used to simulate the effects of changing temperature on the kinetics of biochemical systems and applied this strategy to analyze the effects of hypothermia on thrombin generation. We found that thrombin generation can be noticeably impaired in subjects with different blood plasma composition even in moderate hypothermia. Our work provides mechanistic support to the notion that thrombin generation impairment may be a key factor in coagulopathy induced by hypothermia and complicated by blood plasma dilution.
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Hagemo JS, Næss PA, Johansson P, Windeløv NA, Cohen MJ, Røislien J, Brohi K, Heier HE, Hestnes M, Gaarder C. Evaluation of TEG(®) and RoTEM(®) inter-changeability in trauma patients. Injury 2013; 44:600-5. [PMID: 23260867 DOI: 10.1016/j.injury.2012.11.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 10/29/2012] [Accepted: 11/17/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Massive haemorrhage is a leading cause of preventable deaths in trauma. Traumatic coagulopathy is frequently present early after trauma, and is associated with increased mortality. A number of recent trials suggest that viscoelastic haemostatic assays (VHA), such as thromboelastography and thromboelastometry, are useful tools in guiding transfusion. Treatment algorithms exist for the use of VHAs but are not validated in traumatic haemorrhage. In this study we examined the inter-changeability of two commonly used VHAs, TEG(®) and RoTEM(®). METHODS A total of 184 trauma patients over the age of 18, requiring full trauma team activation, were included at three different hospitals in three different countries (Copenhagen, Denmark, San Francisco, CA, USA and Oslo, Norway). Blood samples were drawn immediately upon arrival, and TEG(®) and RoTEM(®) analyzed simultaneously. Correlations were calculated using. Spearman's rank correlation coefficient. Agreement was evaluated by Bland-Altman plots and calculation of limits of agreement. RESULTS The mean ISS in the total population was 17, and the mortality was 16.5%. Mean base excess was -2.8 (SD: 4.2). The correlation coefficient for corresponding values for the two devices was 0.24 for the R-time vs CT in all centres combined. For the K-time vs CFT the correlation was 0.48, for the α-angleTEG vs α-angleRoTEM 0.44, and for MA vs MCF 0.76. Limits of agreement exceeded the preset clinically acceptable deviation of 10% for all variables in all centres except for MA/MCF in one centre (Copenhagen). Generally, correlation coefficients were lower and agreement poorer in the one centre (Oslo) where measurements were performed bedside by clinicians. CONCLUSION Inter-changeability between TEG(®) and RoTEM(®) is limited in the trauma setting. Agreement seems poorer when clinicians operate the devices. Development and validation of separate treatment algorithms for the two devices is required.
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Affiliation(s)
- Jostein S Hagemo
- Department of Research, Norwegian Air Ambulance, Drøbak, Norway.
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Kaczynski J, Wilczynska M, Hilton J, Fligelstone L. Impact of crystalloids and colloids on coagulation cascade during trauma resuscitation-a literature review. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2052-6229-1-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Zhang J, Jiang R, Liu L, Watkins T, Zhang F, Dong JF. Traumatic brain injury-associated coagulopathy. J Neurotrauma 2012; 29:2597-605. [PMID: 23020190 DOI: 10.1089/neu.2012.2348] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Traumatic injury is a common cause of coagulopathy, primarily due to blood loss and hemodilution secondary to fluid resuscitation. Traumatic injury-associated coagulopathy often follows a course of transition from hyper- to hypocoagulable state exemplified in disseminated intravascular coagulation. The incidence of coagulopathy is significantly higher in patients with traumatic brain injury (TBI), especially those with penetrating trauma compared to injury to the trunk and limbs. This occurs despite the fact that patients with isolated TBI bleed less and receive restricted volume load of fluids. TBI-associated coagulopathy is extensively documented to associate with poor clinical outcomes, but its pathophysiology remains poorly understood. Studies in the past have shown that brain tissue is highly enriched in key procoagulant molecules. This review focuses on the biochemical and cellular characteristics of these molecules and pathways that could make brain uniquely procoagulant and prone to coagulopathy. Understanding this unique procoagulant environment will help to identify new therapeutic targets that could reverse a state of coagulopathy with minimal impacts on hemostasis, a critical requirement for neurosurgical treatments of TBI.
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Affiliation(s)
- Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University and Tianjin Neurology Institute, Tianjin, China
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Francis WR, Bodger OG, Pallister I. Altered leucocyte progenitor profile in human bone marrow from patients with major trauma during the recovery phase. Br J Surg 2012; 99:1591-9. [DOI: 10.1002/bjs.8919] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Changes in human bone marrow associated with the systemic inflammatory response to injury are little understood. It was hypothesized that major trauma results in an altered bone marrow leucocyte progenitor profile, with either uniform depletion or the balance between multipotent and committed progenitors varying, depending on whether self-renewal is favoured over differentiation.
Methods
Bone marrow aspirate and peripheral blood samples were obtained at definitive surgery in adults with pelvic fractures from blunt trauma (major trauma with Injury Severity Score (ISS) at least 18, or isolated fractures) and control patients undergoing iliac crest bone grafting. ISS, interval to surgery and transfusion in the first 24 h were recorded. Bone marrow aspirate flow cytometry was used to identify haemopoietic progenitor cells (CD34+), multipotent cells (CD34+ CD45+ CD38−) and oligopotent cells (CD34+ CD45+ CD38lo/+ and CD34+ CD45+ CD38BRIGHT(++ +) subsets). Peripheral blood levels of inflammatory markers were measured, and the ratio of immature to mature (CD35−/CD35+) granulocytes was determined.
Results
The median (range) interval between injury and sampling was 7 (1–21) and 5 (1–21) days in the major trauma and isolated fracture groups respectively. The CD34+ pool was significantly depleted in the major trauma group (P = 0·017), particularly the CD34+ CD45+ CD38BRIGHT(++ +) oligopotent pool (P = 0·003). Immature CD35− granulocytes increased in bone marrow with increasing injury severity (P = 0·024) and massive transfusion (P = 0·019), and in peripheral blood with increasing interval to surgery (P = 0·005).
Conclusion
Major blunt trauma resulted in changes in the bone marrow CD34+ progenitor pool. At the point in recovery when these samples were obtained, oligopotent progenitors were lost from the bone marrow, with continued release of immature cells.
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Affiliation(s)
- W R Francis
- Institute of Life Science, College of Medicine, Swansea University, UK
| | - O G Bodger
- Institute of Life Science, College of Medicine, Swansea University, UK
| | - I Pallister
- Department of Trauma and Orthopaedics, Morriston Hospital, Swansea, UK
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Shere-Wolfe RF, Galvagno SM, Grissom TE. Critical care considerations in the management of the trauma patient following initial resuscitation. Scand J Trauma Resusc Emerg Med 2012; 20:68. [PMID: 22989116 PMCID: PMC3566961 DOI: 10.1186/1757-7241-20-68] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 08/28/2012] [Indexed: 12/20/2022] Open
Abstract
Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.
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Affiliation(s)
- Roger F Shere-Wolfe
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S. Greene St, Ste. T1R77, Baltimore, MD 21201, USA.
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Billeter AT, Qadan M, Druen D, Gardner SA, The T, Polk HC. Does clinically relevant temperature change miRNA and cytokine expression in whole blood? J Interferon Cytokine Res 2012; 32:485-94. [PMID: 22909186 DOI: 10.1089/jir.2011.0105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Unintentional hypothermia is a well-described risk factor for death and complications after elective and emergency surgery. The molecular mechanisms by which hypothermia exerts its detrimental effects are not well understood. Differences in cytokine production and the overall cell function have been reported under hypothermic conditions. We investigated the effect of a range of clinically relevant temperatures on cytokine production and microRNA (miRNA) expression in a whole-blood model. We found that there was a wide variation in tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and IL-10 production among different subjects, ranging from low to high TNF-α producers. The intersubject variation can also be found on the transcriptional level: high producers had higher upregulation of TNF-α messenger RNA than intermediate and low producers. This variation in TNF-α was reproducible in each individual. Temperature seems to modulate TNF-α production among these different groups. miRNA expression was modulated by temperature. miRNA-181a might control, or be a part of the mechanism which controls, TNF-α production. However, an analysis of whole-leukocyte RNA does not allow the investigation of mechanisms in a specific leukocyte subpopulation such as monocytes, because these changes may be concealed by miRNA expression changes in the other leukocyte subsets. In conclusion, TNF-α, IL-6, and IL-10 production is highly variable among different persons, but temperature affects the expression of miRNAs, which may consequently alter the production of TNF-α.
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Affiliation(s)
- Adrian T Billeter
- Hiram C. Polk Jr. MD Department of Surgery, Price Institute of Surgical Research, University of Louisville School of Medicine, Louisville, KY 40292, USA.
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Johansson PI, Stensballe J, Ostrowski SR. Current management of massive hemorrhage in trauma. Scand J Trauma Resusc Emerg Med 2012; 20:47. [PMID: 22776724 PMCID: PMC3439269 DOI: 10.1186/1757-7241-20-47] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 07/09/2012] [Indexed: 02/06/2023] Open
Abstract
Hemorrhage remains a major cause of potentially preventable deaths. Trauma and massive transfusion are associated with coagulopathy secondary to tissue injury, hypoperfusion, dilution, and consumption of clotting factors and platelets. Concepts of damage control surgery have evolved prioritizing early control of the cause of bleeding by non-definitive means, while hemostatic control resuscitation seeks early control of coagulopathy.Hemostatic resuscitation provides transfusions with plasma and platelets in addition to red blood cells in an immediate and sustained manner as part of the transfusion protocol for massively bleeding patients. Although early and effective reversal of coagulopathy is documented, the most effective means of preventing coagulopathy of massive transfusion remains debated and randomized controlled studies are lacking. Viscoelastical whole blood assays, like TEG and ROTEM however appear advantageous for identifying coagulopathy in patients with severe hemorrhage as opposed the conventional coagulation assays.In our view, patients with uncontrolled bleeding, regardless of it's cause, should be treated with hemostatic control resuscitation involving early administration of plasma and platelets and earliest possible goal-directed, based on the results of TEG/ROTEM analysis. The aim of the goal-directed therapy should be to maintain a normal hemostatic competence until surgical hemostasis is achieved, as this appears to be associated with reduced mortality.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Surgery, Center for Translational Injury Research (CeTIR),, University of Texas Medical School at Houston, Houston, TX, USA
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Anesthesiology, HOC, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
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Sawyer MM, Myers G, Humphrey J, Chandler M. Trauma and Thrombelastography. Semin Cardiothorac Vasc Anesth 2012; 16:142-52. [DOI: 10.1177/1089253212446994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Bleeding disorders associated with trauma are of paramount importance when dealing with the acutely injured individual. Statistically, up to 40% of trauma related deaths are assumed to be related to hemorrhage.1,2 Historically, there have been many varying positions on the way to handle this entity.3–5 Ironically, it is not always the injury but the physiologic sequelae of that injury that lead to trauma associated deaths.6,7 Over time, newer theories have been developed to help the clinician begin to understand the etiology and treatment of this process.6,8,9 The purpose of this paper is to review current literature and explain how these new concepts helped change practice in an urban, academic, Level One Trauma Center.
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Affiliation(s)
| | - Greg Myers
- Denver Health and Hospital, Denver, CO, USA
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Jiang H, Wang J. Emergency strategies and trends in the management of liver trauma. Front Med 2012; 6:225-33. [PMID: 22673827 DOI: 10.1007/s11684-012-0186-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 01/10/2012] [Indexed: 12/14/2022]
Abstract
The liver is the most frequently injured organ during abdominal trauma. The management of hepatic trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation, and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques. Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The present review presents emergency strategies and trends in the management of liver trauma.
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Affiliation(s)
- Hongchi Jiang
- Department of Hepatic Surgery, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Chinnery GE, Krige JEJ, Kotze UK, Navsaria P, Nicol A. Surgical management and outcome of civilian gunshot injuries to the pancreas. Br J Surg 2012; 99 Suppl 1:140-8. [PMID: 22441869 DOI: 10.1002/bjs.7761] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreatic injuries are uncommon but result in substantial morbidity and mortality. This study evaluated the factors associated with morbidity and mortality in civilian patients with pancreatic gunshot wounds. METHODS This was a single-institution, retrospective review of patients with gunshot wounds of the pancreas treated from 1976 to 2009 in Cape Town, South Africa. Univariable and multivariable analyses were performed. RESULTS A total of 219 patients (205 male, median age 27 years) had pancreatic American Association for the Surgery of Trauma grade I-II (111 patients) and grade III-V (108) gunshot injuries to the pancreatic head (72), neck (8), body (75) and tail (64). The patients underwent 239 laparotomies, including drainage of the pancreas (169), distal pancreatectomy (59) and pancreaticoduodenectomy (11). Some 218 patients had 642 associated intra-abdominal and 91 vascular injuries. Forty-three (19.6 per cent) required an initial damage control procedure. A total of 150 patients (68.5 per cent) had 407 postoperative complications (median 4, range 1-7). The 46 patients (21.0 per cent) who died had a median of 3 (range 1-7) complications. Median (range) intensive care unit and total hospital stay were 5 (1-153) and 11 (1-255) days respectively. Multivariable analyses identified age, high-grade pancreatic injury, associated vascular injuries and need for repeat laparotomy as predictors of morbidity. Age, shock on admission, need for damage control surgery, high-grade pancreatic injuries and associated vascular injuries were significant factors associated with mortality. CONCLUSION Morbidity and mortality rates were high after gunshot injuries to the pancreas. Initial shock and severe injury combined with need for damage control surgery were associated with the highest risk of death.
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Affiliation(s)
- G E Chinnery
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit and Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
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Ho AMH, Dion PW, Yeung JHH, Joynt GM, Lee A, Ng CSH, Chang A, So FL, Cheung CW. Simulation of survivorship bias in observational studies on plasma to red blood cell ratios in massive transfusion for trauma. Br J Surg 2012; 99 Suppl 1:132-9. [PMID: 22441868 DOI: 10.1002/bjs.7732] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Observational studies on injured patients requiring massive transfusion have found a survival advantage associated with use of equivalent number of units of fresh frozen plasma (FFP) and packed red blood cells (RBCs) compared with use of FFP based on conventional guidelines. However, a survivorship bias might have favoured the higher use of FFP because patients who died early never had the chance to receive sufficient FFP to match the number of RBC units transfused. METHODS A Markov model using trauma data from local hospitals was constructed and various FFP transfusion scenarios were applied in Monte Carlo simulations in which the relative risk of death associated with exposure to high FFP transfusion was set at 1.00, so that the FFP : RBC ratio had no influence on mortality outcome. RESULTS Simulation results showed that the relative risk associated with exposure to high FFP transfusion was less than 1.00 (0.33-0.56 based on programmed delays in achieving an FFP : RBC ratio of 1 : 1-2), thus demonstrating a survivorship bias in favour of FFP : RBC equal to or more than 1 : 1-2 in certain observational trauma studies. This bias was directly proportional to the delay in achieving a FFP : RBC ratio of 1 : 1-2 during resuscitation. CONCLUSION Some observational studies comparing low and high FFP administration in injured patients requiring massive transfusion probably involve survivorship bias that inflates or creates a survival advantage in favour of a higher FFP : RBC ratio.
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Affiliation(s)
- A M-H Ho
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, China.
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Abstract
PURPOSE OF REVIEW Coagulation management remains a challenge for anesthesiologists involved in cardiovascular surgery as the population undergoing surgery becomes older and presents with more comorbidities. These patients are frequently treated with one or more agents that directly affect coagulation. This review will discuss what is known and the treatments available to manage coagulation in the perioperative setting of cardiac surgery. RECENT FINDINGS New antithrombotics will be discussed as well as their proposed substitution in the preoperative period. The review will also describe the different products available in Europe for the treatment of bleeding and coagulopathy. Finally, the use of new monitoring devices will be discussed. SUMMARY The introduction of new drugs with different mechanisms of action adds to the complexity of coagulation management during cardiovascular surgery. Monitoring needs to be developed and improved, especially for evaluating platelet function.
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Raymer JM, Flynn LM, Martin RF. Massive Transfusion of Blood in the Surgical Patient. Surg Clin North Am 2012; 92:221-34, vii. [DOI: 10.1016/j.suc.2012.01.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Ting J. The rewarming benefit of anterior torso heat pad application in mildly hypothermic conscious adult trauma patients remains inconclusive. SCANDINAVIAN JOURNAL OF TRAUMA, RESUSCITATION AND EMERGENCY MEDICINE 2012; 20:17. [PMID: 22385688 PMCID: PMC3314547 DOI: 10.1186/1757-7241-20-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 03/04/2012] [Indexed: 11/10/2022]
Abstract
The rewarming benefit of anterior torso heat pad application in mildly hypothermic conscious adult trauma patients remains inconclusive in this randomized comparative clinical trial. There was no between-group rewarming gain in ear canal temperature when an anterior torso chemical heat pad was compared with blankets. Patient awareness, and favorable perception of, being administered the active intervention (heat pad) could explain the significant improvement in patient-rated cold discomfort discerned with the heat pad. In the context of marginal demonstrated benefit, it would have been informative to ascertain adverse effects related to the heat pad, including burn injury to the chest wall.
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Abstract
Massive bleeding accounts for more than 50% of all trauma-related deaths within the first 48h following hospital admission and it can significantly raise the mortality rate of any kind of surgery. Despite this great clinical relevance, evidence on the management of massive bleeding is surprisingly scarce, and its treatment is often based on empirical grounds. Successful treatment of massive haemorrhage depends on better understanding of the associated physiological changes as well as on good team work among the different specialists involved in the management of such a complex condition.
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Affiliation(s)
- Marco Marietta
- Dipartimento Integrato di Oncologia, Ematologia e Patologie dell'Apparto Respiratorio, U.O.C. di Ematologia, Azienda Ospedaliero-Universitaria di Modena, Italy.
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Bader MK. Clinical q & a: translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2011; 1:165-71. [PMID: 24717045 DOI: 10.1089/ther.2011.1506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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