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Bozzay JD, Gurney JM, Purcell RL, Bradley MJ, Buzzelli MD. Reflections on the US Withdrawal from Afghanistan: Insight into the Evolving Battlefield and the Need for Adaptive Responsiveness. J Am Coll Surg 2024; 238:808-813. [PMID: 38456843 DOI: 10.1097/xcs.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Joseph D Bozzay
- From the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD (Bozzay, Bradley, Buzzelli)
- Department of Surgery, Womack Army Medical Center, Fort Liberty, NC (Bozzay)
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Medical Center, Columbus, OH (Bozzay)
| | - Jennifer M Gurney
- Department of Surgery, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, TX (Gurney)
- Joint Trauma System, Falls Church, VA (Gurney)
| | - Richard L Purcell
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX (Purcell)
| | - Matthew J Bradley
- From the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD (Bozzay, Bradley, Buzzelli)
| | - Mark D Buzzelli
- From the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD (Bozzay, Bradley, Buzzelli)
- Division of Trauma, Burns & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Health System, Miami, FL (Buzzelli)
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Duron V, Schmoke N, Ichinose R, Stylianos S, Kernie SG, Dayan PS, Slidell MB, Stulce C, Chong G, Williams RF, Gosain A, Morin NP, Nasr IW, Kudchadkar SR, Bolstridge J, Prince JM, Sathya C, Sweberg T, Dorrello NV. Delphi Process for Validation of Fluid Treatment Algorithm for Critically Ill Pediatric Trauma Patients. J Surg Res 2024; 295:493-504. [PMID: 38071779 DOI: 10.1016/j.jss.2023.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/10/2023] [Accepted: 11/13/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION While intravenous fluid therapy is essential to re-establishing volume status in children who have experienced trauma, aggressive resuscitation can lead to various complications. There remains a lack of consensus on whether pediatric trauma patients will benefit from a liberal or restrictive crystalloid resuscitation approach and how to optimally identify and transition between fluid phases. METHODS A panel was comprised of physicians with expertise in pediatric trauma, critical care, and emergency medicine. A three-round Delphi process was conducted via an online survey, with each round being followed by a live video conference. Experts agreed or disagreed with each aspect of the proposed fluid management algorithm on a five-level Likert scale. The group opinion level defined an algorithm parameter's acceptance or rejection with greater than 75% agreement resulting in acceptance and greater than 50% disagreement resulting in rejection. The remaining were discussed and re-presented in the next round. RESULTS Fourteen experts from five Level 1 pediatric trauma centers representing three subspecialties were included. Responses were received from 13/14 participants (93%). In round 1, 64% of the parameters were accepted, while the remaining 36% were discussed and re-presented. In round 2, 90% of the parameters were accepted. Following round 3, there was 100% acceptance by all the experts on the revised and final version of the algorithm. CONCLUSIONS We present a validated algorithm for intavenous fluid management in pediatric trauma patients that focuses on the de-escalation of fluids. Focusing on this time point of fluid therapy will help minimize iatrogenic complications of crystalloid fluids within this patient population.
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Affiliation(s)
- Vincent Duron
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York.
| | - Nicholas Schmoke
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Rika Ichinose
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Steven Stylianos
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Steven G Kernie
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Peter S Dayan
- Department of Emergency Medicine, NewYork-Presbyterian/Columbia University Valegos College of Physicians and Surgeons, New York, New York
| | - Mark B Slidell
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Casey Stulce
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine Comer Children's Hospital, Chicago, Illinois
| | - Grace Chong
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine Comer Children's Hospital, Chicago, Illinois
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ankush Gosain
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Denver, Colorado
| | - Nicholas P Morin
- Division of Critical Care Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Isam W Nasr
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Bolstridge
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose M Prince
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York
| | - Chethan Sathya
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York
| | - Todd Sweberg
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical, Northwell Health, New Hyde Park, New York
| | - N Valerio Dorrello
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
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Duron VP, Ichinose R, Stewart LA, Porigow C, Fan W, Rubsam JM, Stylianos S, Dorrello NV. Pilot randomized controlled trial of restricted versus liberal crystalloid fluid management in pediatric post-operative and trauma patients. Pilot Feasibility Stud 2023; 9:185. [PMID: 37941073 PMCID: PMC10631167 DOI: 10.1186/s40814-023-01408-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Intravenous (IV) fluid therapy is essential in the treatment of critically ill pediatric surgery and trauma patients. Recent studies have suggested that aggressive fluids may be detrimental to patients. Prospective studies are needed to compare liberal to restricted fluid management in these patients. The primary objective of this pilot trial is to test study feasibility-recruitment and adherence to the study treatment algorithm. METHODS We conducted a two-part pilot randomized controlled trial (RCT) comparing liberal to restricted crystalloid fluid management in 50 pediatric post-operative (1-18 years) and trauma (1-15 years) patients admitted to our pediatric intensive care unit (PICU). Patients were randomized to a high (liberal) volume or low (restricted) volume algorithm using unblinded, blocked randomization. A revised treatment algorithm was used after the 29th patient for the second part of the RCT. The goal of the trial was to determine the feasibility of conducting an RCT at a single site for recruitment and retention. We also collected data on the safety of study interventions and clinical outcomes, including pulmonary, infectious, renal, post-operative, and length of stay outcomes. RESULTS Fifty patients were randomized to either liberal (n = 26) or restricted (n = 24) fluid management strategy. After data was obtained on 29 patients, a first study analysis was performed. The volume of fluid administered and triggers for intervention were adapted to optimize the treatment effect and clarity of outcomes. Updated and refined fluid management algorithms were created. These were used for the second part of the RCT on patients 30-50. During this second study period, 54% (21/39, 95% CI 37-70%) of patients approached were enrolled in the study. Of the patients enrolled, 71% (15/21, 95% CI 48-89%) completed the study. This met our a priori recruitment and retention criteria for success. A data safety monitoring committee concluded that no adverse events were related to study interventions. Although the study was not powered to detect differences in outcomes, after the algorithm was revised, we observed a non-significant trend towards improved pulmonary outcomes in patients on the restricted arm, including decreased need for and time on oxygen support and decreased need for mechanical ventilation. CONCLUSION We demonstrated the feasibility and safety of conducting a single-site RCT comparing liberal to restricted crystalloid fluid management in critically ill pediatric post-operative and trauma patients. We observed trends in improved pulmonary outcomes in patients undergoing restricted fluid management. A definitive multicenter RCT comparing fluid management strategies in these patients is warranted. TRIAL REGISTRATION ClinicalTrials.gov, NCT04201704 . Registered 17 December 2019-retrospectively registered.
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Affiliation(s)
- Vincent P Duron
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA.
| | - Rika Ichinose
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Latoya A Stewart
- Columbia University Vagelos College of Physicians and Surgeons, 630W 168Th Street, New York, NY, 10032, USA
| | - Chloe Porigow
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Weijia Fan
- Department of Biostatistics, Columbia University Mailman School of Public Health, 722W 168Th Street, New York, NY, 10032, USA
| | - Jeanne M Rubsam
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Steven Stylianos
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Nicolino V Dorrello
- Department of Pediatric Critical Care, CUIMC/New York-Presbyterian Morgan Stanley Children's Hospital, New York City, USA
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Hsu CH, Chen CH, Chou PH. Potential Limitations for Assessing the Association of Whole Blood With Survival in Patients With Severe Hemorrhage. JAMA Surg 2023; 158:1226-1227. [PMID: 37379031 DOI: 10.1001/jamasurg.2023.1840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Affiliation(s)
- Chia-Hao Hsu
- Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Hwan Chen
- Orthopaedic Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Hsi Chou
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Rayatdoost F, Grottke O. The Use of Large Animal Models in Trauma and Bleeding Studies. Hamostaseologie 2023; 43:360-373. [PMID: 37696297 DOI: 10.1055/a-2118-1431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Major trauma often results in significant bleeding and coagulopathy, posing a substantial clinical burden. To understand the underlying pathophysiology and to refine clinical strategies to overcome coagulopathy, preclinical large animal models are often used. This review scrutinizes the clinical relevance of large animal models in hemostasis research, emphasizing challenges in translating findings into clinical therapies. METHODS We conducted a thorough search of PubMed and EMBASE databases from January 1, 2010, to December 31, 2022. We used specific keywords and inclusion/exclusion criteria centered on large animal models. RESULTS Our review analyzed 84 pertinent articles, including four animal species: pigs, sheep, dogs, and nonhuman primates (NHPs). Eighty-five percent of the studies predominantly utilized porcine models. Meanwhile, sheep and dogs were less represented, making up only 2.5% of the total studies. Models with NHP were 10%. The most frequently used trauma models involved a combination of liver injury and femur fractures (eight studies), arterial hemorrhage (seven studies), and a combination of hemodilution and liver injury (seven studies). A wide array of coagulation parameters were employed to assess the efficacy of interventions in hemostasis and bleeding control. CONCLUSIONS Recognizing the diverse strengths and weaknesses of large animal models is critical for trauma and hemorrhage research. Each model is unique and should be chosen based on how well it aligns with the specific scientific objectives of the study. By strategically considering each model's advantages and limitations, we can enhance our understanding of trauma and hemorrhage pathophysiology and further advance the development of effective treatments.
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Affiliation(s)
- Farahnaz Rayatdoost
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA Pediatr 2023; 177:693-699. [PMID: 37213096 PMCID: PMC10203962 DOI: 10.1001/jamapediatrics.2023.1291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/01/2023] [Indexed: 05/23/2023]
Abstract
Importance Optimal hemostatic resuscitation in pediatric trauma is not well defined. Objective To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children. Design, Setting, and Participants This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023. Exposure Receipt of a blood product transfusion in the prehospital setting compared with the emergency department. Main Outcomes and Measures The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications. Results Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10). Conclusions and Relevance In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.
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Morgan CG, Neidert LE, Ozuna KM, Glaser JJ, Pusateri AE, Tiller MM, Cardin S. PREHOSPITAL PLASMA IS NONINFERIOR TO WHOLE BLOOD FOR RESTORATION OF CEREBRAL OXYGENATION IN A RHESUS MACAQUE MODEL OF TRAUMATIC SHOCK AND HEMORRHAGE. Shock 2023; 60:146-152. [PMID: 37179251 DOI: 10.1097/shk.0000000000002148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
ABSTRACT Introduction: Traumatic shock and hemorrhage (TSH) is a leading cause of preventable death in military and civilian populations. Using a TSH model, we compared plasma with whole blood (WB) as prehospital interventions, evaluating restoration of cerebral tissue oxygen saturation (CrSO 2 ), systemic hemodynamics, colloid osmotic pressure (COP) and arterial lactate, hypothesizing plasma would function in a noninferior capacity to WB, despite dilution of hemoglobin (Hgb). Methods: Ten anesthetized male rhesus macaques underwent TSH before randomization to receive a bolus of O(-) WB or AB(+) plasma at T0. At T60, injury repair and shed blood (SB) to maintain MAP > 65 mm Hg began, simulating hospital arrival. Hematologic data and vital signs were analyzed via t test and two-way repeated measures ANOVA, data presented as mean ± SD, significance = P < 0.05. Results: There were no significant group differences for shock time, SB volume, or hospital SB. At T0, MAP and CrSO 2 significantly declined from baseline, though not between groups, normalizing to baseline by T10. Colloid osmotic pressure declined significantly in each group from baseline at T0 but restored by T30, despite significant differences in Hgb (WB 11.7 ± 1.5 vs. plasma 6.2 ± 0.8 g/dL). Peak lactate at T30 was significantly higher than baseline in both groups (WB 6.6 ± 4.9 vs. plasma 5.7 ± 1.6 mmol/L) declining equivalently by T60. Conclusions: Plasma restored hemodynamic support and CrSO 2 , in a capacity not inferior to WB, despite absence of additional Hgb supplementation. This was substantiated via return of physiologic COP levels, restoring oxygen delivery to microcirculation, demonstrating the complexity of restoring oxygenation from TSH beyond simply increasing oxygen carrying capacity.
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Affiliation(s)
- Clifford G Morgan
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas
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Bozzay JD, Walker PF, Atwood RE, DeSpain RW, Parker WJ, Chertow DS, Mares JA, Leonhardt CL, Elster EA, Bradley MJ. Development, refinement, and characterization of a nonhuman primate critical care environment. PLoS One 2023; 18:e0281548. [PMID: 36930612 PMCID: PMC10022766 DOI: 10.1371/journal.pone.0281548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 01/17/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Systemic inflammatory response remains a poorly understood cause of morbidity and mortality after traumatic injury. Recent nonhuman primate (NHP) trauma models have been used to characterize the systemic response to trauma, but none have incorporated a critical care phase without the use of general anesthesia. We describe the development of a prolonged critical care environment with sedation and ventilation support, and also report corresponding NHP biologic and inflammatory markers. METHODS Eight adult male rhesus macaques underwent ventilation with sedation for 48-96 hours in a critical care setting. Three of these NHPs underwent "sham" procedures as part of trauma control model development. Blood counts, chemistries, coagulation studies, and cytokines/chemokines were collected throughout the study, and histopathologic analysis was conducted at necropsy. RESULTS Eight NHPs were intentionally survived and extubated. Three NHPs were euthanized at 72-96 hours without extubation. Transaminitis occurred over the duration of ventilation, but renal function, acid-base status, and hematologic profile remained stable. Chemokine and cytokine analysis were notable for baseline fold-change for Il-6 and Il-1ra (9.7 and 42.7, respectively) that subsequently downtrended throughout the experiment unless clinical respiratory compromise was observed. CONCLUSIONS A NHP critical care environment with ventilation support is feasible but requires robust resources. The inflammatory profile of NHPs is not profoundly altered by sedation and mechanical ventilation. NHPs are susceptible to the pulmonary effects of short-term ventilation and demonstrate a similar bioprofile response to ventilator-induced pulmonary pathology. This work has implications for further development of a prolonged care NHP model.
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Affiliation(s)
- Joseph D. Bozzay
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
- * E-mail:
| | - Patrick F. Walker
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Rex E. Atwood
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Robert W. DeSpain
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - William J. Parker
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Daniel S. Chertow
- Emerging Pathogens Section, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - John A. Mares
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Crystal L. Leonhardt
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Eric A. Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
| | - Matthew J. Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
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Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma. J Trauma Acute Care Surg 2023; 94:S29-S35. [PMID: 36156051 DOI: 10.1097/ta.0000000000003801] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Increasing rates of penetrating trauma in the United States makes rapid identification of hemorrhagic shock, coagulopathy, and early initiation of balanced resuscitation in injured children of critical importance. Hemorrhagic shock begins early after injury and can be challenging to identify in children, as hypotension is a late sign that a child is on the verge of circulatory collapse and should be aggressively resuscitated. Recent data support shifting away from crystalloid and toward early resuscitation with blood products because of worse coagulopathy and clinical outcomes in injured patients resuscitated with crystalloid. Multicenter studies have found improved survival in injured children who receive balanced resuscitation with higher fresh frozen plasma: red blood cell ratios. Whole blood is an efficient way to achieve balanced resuscitation in critically injured children with limited intravenous access and decreased exposure to multiple donors. Administration of cold-stored, low-titer O-negative whole blood (LTOWB) appears to be safe in adults and children and may be associated with improved survival in children with life-threatening hemorrhage. Many pediatric centers use RhD-negative LTOWB for all female children because of the risk of hemolytic disease of the fetus and newborn (0-6%); however. there is a scarcity of LTOWB compared with the demand. Low risks of hemolytic disease of the fetus and newborn affecting a future pregnancy must be weighed against high mortality rates in delayed blood product administration in children in hemorrhagic shock. Survey studies involving key stakeholder's opinions on pediatric blood transfusion practices are underway. Existing pediatric-specific literature on trauma resuscitation is often limited and underpowered; multicenter prospective studies are urgently needed to define optimal resuscitation products and practices in injured children in an era of increasing penetrating trauma.
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Trauma provision in South-West Nigeria: Epidemiology, challenges and priorities. Afr J Emerg Med 2022; 12:276-280. [PMID: 35795816 PMCID: PMC9249585 DOI: 10.1016/j.afjem.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/04/2022] [Accepted: 05/26/2022] [Indexed: 11/20/2022] Open
Abstract
This article highlights the epidemiology of trauma and common challenges of trauma provision in the region. It elucidates the urgent need to improve trauma care in Nigeria and other African countries. Furthermore, it advocates for the development of a regionalised trauma system and centralised trauma registry amongst others.
Trauma is a crucial public health problem that has been overlooked by developing countries including Nigeria. It has led to a worsening trauma trend as recent data suggests. The South-West Region of Nigeria remains one of the regions with the most injury prevalence. Since the introduction of the trauma system over half a century ago, regionalised trauma systems have become increasingly effective in changing the dynamics of trauma care and outcomes. However, similar to most developing countries trauma system is yet to be established in any region in Nigeria. This is also met by a lack of a centralised trauma registry, poor implementation of primary prevention practices, an informal prehospital care system, and poorly organised in-hospital care for trauma victims. Reversing these challenges could be a propelling force to the revolution of trauma provision in the region and extension to the nation, Africa, and other developing countries. Nevertheless, the stakeholders such as the government, legislature, Non-Governmental-Organisations, law-enforcement agencies, healthcare institutions, trauma experts, and the public have a huge role.
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Morgan KM, Gaines BA, Leeper CM. Pediatric Trauma Resuscitation Practices. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00238-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bush K, Shea L, San Roman J, Pailloz E, Gaughan J, Porter J, Goldenberg-Sandau A. Whole Blood in Trauma Resuscitation: What is the Real Cost? J Surg Res 2022; 275:155-160. [DOI: 10.1016/j.jss.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 12/30/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
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Ask A, Eltringham-Smith L, Bhakta V, Donkor DA, Pryzdial EL, Sheffield WP. Spotlight on animal models of acute traumatic coagulopathy: An update. Transfus Apher Sci 2022; 61:103412. [DOI: 10.1016/j.transci.2022.103412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Thrombin Generation in Trauma Patients: How Do we Navigate Through Scylla and Charybdis? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00502-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wallen TE, Singer KE, Morris MC, Blakeman T, Stevens-Topie SM, Strilka R, Pritts TA, Goodman MD. Blood product resuscitation mitigates the effects of aeromedical evacuation after polytrauma. J Trauma Acute Care Surg 2022; 92:12-20. [PMID: 34932039 DOI: 10.1097/ta.0000000000003433] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The combined injury of traumatic brain injury and hemorrhagic shock has been shown to worsen coagulopathy and systemic inflammation, thereby increasing posttraumatic morbidity and mortality. Aeromedical evacuation to definitive care may exacerbate postinjury morbidity because of the inherent hypobaric hypoxic environment. We hypothesized that blood product resuscitation may mitigate the adverse physiologic effects of postinjury flight. METHODS An established porcine model of controlled cortical injury was used to induce traumatic brain injury. Intracerebral monitors were placed to record intracranial pressure, brain tissue oxygenation, and cerebral perfusion. Each of the 42 pigs was hemorrhaged to a goal mean arterial pressure of 40 ± 5 mm Hg for 1 hour. Pigs were grouped according to resuscitation strategy used-Lactated Ringer's (LR) or shed whole blood (WB)-then placed in an altitude chamber for 2 hours at ground, 8,000 ft, or 22,000 ft, and then observed for 4 hours. Hourly blood samples were analyzed for proinflammatory cytokines and lactate. Internal jugular vein blood flow was monitored continuously for microbubble formation with altitude changes. RESULTS Cerebral perfusion, tissue oxygenation, and intracranial pressure were unchanged among the six study groups. Venous microbubbles were not observed even with differing altitude or resuscitation strategy. Serum lactate levels from hour 2 of flight to the end of observation were significantly elevated in 22,000 + LR compared with 8,000 + LR and 22,000 + WB. Serum IL-6 levels were significantly elevated in 22,000 + LR compared with 22,000 + WB, 8,000 + LR and ground+LR at hour 1 of observation. Serum tumor necrosis factor-α was significantly elevated at hour 2 of flight in 8,000 + LR versus ground+LR, and in 22,000 + LR vs. 22,000 + WB at hour 1 of observation. Serum IL-1β was significantly elevated hour 1 of flight between 8,000 + LR and ground+LR. CONCLUSION Crystalloid resuscitation during aeromedical transport may cause a prolonged lactic acidosis and proinflammatory response that can predispose multiple-injury patients to secondary cellular injury. This physiologic insult may be prevented by using blood product resuscitation strategies.
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Affiliation(s)
- Taylor E Wallen
- From the Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Ramos-Jimenez RG, Leeper C. Hemostatic Resuscitation in Children. Transfus Med Rev 2021; 35:113-117. [PMID: 34716083 DOI: 10.1016/j.tmrv.2021.06.008] [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: 05/14/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
Trauma is a major source of morbidity and mortality for children worldwide; life-threatening hemorrhage is a primary cause of preventable death. Essential interventions in children with life-threatening hemorrhage include hemostatic resuscitation and mechanical control of bleeding. Herein we review pediatric hemostatic resuscitation, a strategy that addresses both hemorrhagic shock and the coagulopathic complications described in patients with major hemorrhage. Some components of hemostatic resuscitation may include: early and aggressive resuscitation with blood products, minimizing crystalloid and hemodilution, antifibrinolytic adjuncts such as tranexamic acid, and the novel use of low-titer group O whole-blood (LTOWB) transfusion in injured children. The following selection of important publications address the current state of hemostatic resuscitation strategies in pediatric trauma patients as well as the remaining knowledge gaps and areas for further research.
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Affiliation(s)
| | - Christine Leeper
- Department of Surgery, UPMC Presbyterian Shadyside, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W. Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C. Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Meledeo MA, Peltier GC, McIntosh CS, Bynum JA, Corley JB, Cap AP. Coagulation function of never frozen liquid plasma stored for 40 days. Transfusion 2021; 61 Suppl 1:S111-S118. [PMID: 34269464 DOI: 10.1111/trf.16526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Never frozen liquid plasma (LP) has limited shelf life versus fresh frozen plasma (FFP) or plasma frozen within 24 h (PF24). Previous studies showed decreasing factor activities after Day (D)14 in thawed FFP but no differences between LP and FFP until D10. This study examined LP function through D40. STUDY DESIGN AND METHODS FFP and PF24 were stored at -20°C until assaying. LP was assayed on D5 then stored (4°C) for testing through D40. A clinical coagulation analyzer measured Factor (F)V, FVIII, fibrinogen, prothrombin time (PT), and activated partial thromboplastin time (aPTT). Thromboelastography (TEG) and thrombogram measured functional coagulation. Ristocetin cofactor assay quantified von Willebrand factor (vWF) activity. Residual platelets were counted. RESULTS FV/FVIII showed diminished activity over time in LP, while PT and aPTT both increased over time. LP vWF declined significantly by D7. Fibrinogen remained high through D40. Thrombin lagtime was delayed in LP but consistent to D40, while peak thrombin was significantly lower in LP but did not significantly decline over time. TEG R-time and angle remained constant. LP and PF24 (with residual platelets) had initially higher TEG maximum amplitudes (MA), but by D14 LP was similar to FFP. CONCLUSION Despite significant declines in some factors in D40 LP, fibrinogen concentration and TEG MA were stable suggesting stored LP provides fibrinogen similarly to frozen plasmas even at D40. LP is easier to store and prepare for prehospital transfusion, important benefits when the alternative is crystalloid.
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Affiliation(s)
| | - Grantham C Peltier
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - Colby S McIntosh
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - James A Bynum
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - Jason B Corley
- Armed Services Blood Program, JBSA-Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
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Khurrum M, Ditillo M, Obaid O, Anand T, Nelson A, Chehab M, Kitts DJ, Douglas M, Bible L, Joseph B. Four-factor prothrombin complex concentrate in adjunct to whole blood in trauma-related hemorrhage: Does whole blood replace the need for factors? J Trauma Acute Care Surg 2021; 91:34-39. [PMID: 33843830 DOI: 10.1097/ta.0000000000003184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of whole blood (WB) for the treatment of hemorrhagic shock and coagulopathy is increasing in civilian trauma patients. Four-factor prothrombin complex concentrate (4-PCC) in adjunct to component therapy showed improved outcomes in trauma patients. Our study aims to evaluate the outcomes of trauma patients who received 4-PCC and WB (4-PCC-WB) compared with WB alone. METHODS We performed a 3-year (2015-2017) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age, ≥18 years) trauma patients who received WB were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups, 4-PCC-WB versus WB alone, and matched in a 1:2 ratio using propensity score matching. Outcome measures were packed red blood cells, plasma, platelets, and cryoprecipitate transfused, in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS) among survivors, and mortality. RESULTS A total of 252 patients (4-PCC-WB, 84; WB alone, 168) were matched. The mean ± SD age was 47 ± 21 years, 63% were males, median Injury Severity Score was 30 (21-40), and 87% had blunt injuries. Patients who received 4-PCC-WB had decreased requirement for packed red blood cell (8 U vs. 10 U, p = 0.04) and fresh frozen plasma (6 U vs. 8 U, p = 0.01) transfusion, lower rates of acute kidney injury (p = 0.03), and ICU LOS (5 days vs. 8 days, p = 0.01) compared with WB alone. There was no difference in the platelet transfusion (p = 0.19), cryoprecipitate transfusion (p = 0.37), hospital LOS (p = 0.72), and in-hospital mortality (p = 0.72) between the two groups. CONCLUSION Our study demonstrates that the use of 4-PCC as an adjunct to WB is associated with a reduction in transfusion requirements and ICU LOS compared with WB alone in the resuscitation of trauma patients. Further studies are required to evaluate the role of PCC with WB in the resuscitation of trauma patients. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
- Muhammad Khurrum
- From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
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Cornillon A, Balbo J, Coffinet J, Floch T, Bard M, Giordano-Orsini G, Malinovsky JM, Kanagaratnam L, Michelet D, Legros V. The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma. Scand J Trauma Resusc Emerg Med 2021; 29:81. [PMID: 34154631 PMCID: PMC8215800 DOI: 10.1186/s13049-021-00876-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation. METHODS Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma. RESULTS One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma. CONCLUSION We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.
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Affiliation(s)
- Adrien Cornillon
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Juliette Balbo
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Julien Coffinet
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Thierry Floch
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France
| | - Mathieu Bard
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France.,University of Reims Champagne Ardennes, Reims, France
| | - Guillaume Giordano-Orsini
- University of Reims Champagne Ardennes, Reims, France.,Department of Emergency Medicine, Reims University Hospital, Reims, France
| | - Jean-Marc Malinovsky
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France.,University of Reims Champagne Ardennes, Reims, France
| | - Lukshe Kanagaratnam
- University of Reims Champagne Ardennes, Reims, France.,Clinical Research Unit, Reims University Hospital, Reims, France
| | - Daphne Michelet
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Vincent Legros
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France.
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Pulliam KE, Joseph B, Veile RA, Friend LA, Makley AT, Caldwell CC, Lentsch AB, Goodman MD, Pritts TA. Expired But Not Yet Dead: Examining the Red Blood Cell Storage Lesion in Extended-Storage Whole Blood. Shock 2021; 55:526-535. [PMID: 32826814 PMCID: PMC7937408 DOI: 10.1097/shk.0000000000001646] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
ABSTRACT Whole blood is a powerful resuscitation strategy for trauma patients but has a shorter shelf life than other blood products. The red blood cell storage lesion in whole blood has not previously been investigated beyond the standard storage period. In the present study, we hypothesized that erythrocytes in stored whole blood exhibit similar aspects of the red blood cell storage lesion and that transfusion of extended storage whole blood would not result in a more severe inflammatory response after hemorrhage in a murine model. To test this hypothesis, we stored low-titer, O-positive, whole blood units, and packed red blood cells (pRBCs) for up to 42 days, then determined aspects of the red blood cell storage lesion. Compared with standard storage pRBCs, whole blood demonstrated decreased microvesicle and free hemoglobin at 21 days of storage and no differences in osmotic fragility. At 42 days of storage, rotational thromboelastometry demonstrated that clotting time was decreased, alpha angle was increased, and clot formation time and maximum clot firmness similar in whole blood as compared with pRBCs with the addition of fresh frozen plasma. In a murine model, extended storage whole blood demonstrated decreased microvesicle formation, phosphatidylserine, and cell-free hemoglobin. After hemorrhage and resuscitation, TNF-a, IL-6, and IL-10 were decreased in mice resuscitated with whole blood. Red blood cell survival was similar at 24 h after transfusion. Taken together, these data suggest that red blood cells within whole blood stored for an extended period of time demonstrate similar or reduced accumulation of the red blood cell storage lesion as compared with pRBCs. Further examination of extended-storage whole blood is warranted.
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Affiliation(s)
- Kasiemobi E Pulliam
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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22
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Prehospital Transfusion of Red Blood Cells and Plasma by an Urban Ground-Based Critical Care Team. Prehosp Disaster Med 2020; 36:170-174. [PMID: 33349291 DOI: 10.1017/s1049023x20001491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Prehospital blood component therapy poses a possible treatment option among patients with severe bleeding. The aim of this paper was to characterize patients receiving prehospital blood component therapy by a paramedic-doctor-staffed, ground-based prehospital critical care (PHCC) service. METHODS Bleeding patients with a clinical need for prehospital blood transfusion were included prospectively. The following data were collected: indication for transfusion, mechanism of injury, vital parameters, units of red blood cells (RBCs)/plasma transfused, degree of shock, demographics, and mortality. RESULTS Twenty-one patients received blood products: 12 (57%) traumatic injuries and nine (43%) non-traumatic bleeds, with a median of 1.5 (range 1.0-2.0) units of RBCs and 1.0 (range 0.0-2.0) unit of plasma. The most frequent trigger to initiate transfusion was on-going excessive bleeding and hypotension. Improved systolic blood pressure (SBP) and milder degrees of shock were observed after transfusion. Mean time from initiation of transfusion to hospital arrival was 24 minutes. In-hospital, 11 patients (61%) received further transfusion and 13 (72%) had urgent surgery within 24 hours. Overall, 28-day mortality was 29% at 24-hours and 33% at 28-days. CONCLUSION Prehospital blood component therapy is feasible in a ground-based prehospital service in a medium-sized Scandinavian city. Following transfusion, patient physiology and degree of shock were significantly improved.
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Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study. J Trauma Acute Care Surg 2020; 89:36-42. [PMID: 32251263 DOI: 10.1097/ta.0000000000002702] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE Therapeutic, level IV.
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Dhara S, Moore EE, Yaffe MB, Moore HB, Barrett CD. Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays? CURRENT TRAUMA REPORTS 2020; 6:69-81. [PMID: 32864298 DOI: 10.1007/s40719-020-00183-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of Review The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient. Recent Findings Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings. Summary Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.
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Affiliation(s)
- Sanjeev Dhara
- University of Chicago School of Medicine, Chicago, IL
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Michael B Yaffe
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
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Pratschke K. Approach to haemoabdomen in small animal patients. IN PRACTICE 2020. [DOI: 10.1136/inp.l6819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Affiliation(s)
- Elizabeth Dauer
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA.
| | - Amy Goldberg
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA
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