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Priya A, Mol N, Singh AK, Aditya AK, Ray AK. "Unveiling the impacts of climatic cold events on the cardiovascular health in animal models". THE SCIENCE OF THE TOTAL ENVIRONMENT 2025; 971:179028. [PMID: 40073773 DOI: 10.1016/j.scitotenv.2025.179028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 02/01/2025] [Accepted: 02/28/2025] [Indexed: 03/14/2025]
Abstract
Climate change is increasingly driving extreme weather events, leading to drastic temperature fluctuations worldwide. While overall temperatures rise, many regions are simultaneously experiencing severe cold spells that threaten the health of human populations, especially to vulnerable populations including the elderly and those with pre-existing conditions. Exposure to cold stress triggers significant physiological and biochemical disruptions. As cardiovascular diseases (CVDs) rank among the leading causes of global morbidity and mortality, the exacerbation of these conditions by cold exposure underscores critical public health challenges. The complex pathophysiological processes in cold-induced CVDs require careful analysis at an organ-system level, making animal models an ideal tool for replicating human physiological and molecular responses in a controlled environment. However, a detailed mechanism linking cold exposure and cardiovascular dysfunction remains incompletely understood, particularly in the context of animal models. Therefore, this comprehensive review aims to address and analyze from traditional rodent models to less conventional ruminants, broilers, canines, and primate animal models to understand cold stress-induced CVDs, with an extensive account of the potential molecular mechanisms and pathways such as oxidative stress, inflammation, vasomotor dysfunction, and apoptosis, along with emerging roles of cold shock proteins (CSPs), etc. We also delve into various potential therapeutic approaches and preventive measures in cold stress conditions. In conclusion, this review is the first to comprehensively address the underexplored cardiovascular complications arising from cold stress and their underlying mechanisms, particularly using animal models. Furthermore, it provides a foundation for advancing the development of more effective and targeted therapies through translational research.
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Affiliation(s)
- Anjali Priya
- Department of Environmental Studies, University of Delhi, New Delhi, India
| | - Nidhi Mol
- Department of Environmental Studies, University of Delhi, New Delhi, India
| | - Alok Kumar Singh
- Department of Zoology, Ramjas College, University of Delhi, New Delhi, India
| | - Abhishek Kumar Aditya
- Department of Medicine, K.D. Medical College, Hospital and Research Centre, Mathura, India
| | - Ashwini Kumar Ray
- Department of Environmental Studies, University of Delhi, New Delhi, India.
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Schmitt FCF, Schöchl H, Brün K, Kreuer S, Schneider S, Hofer S, Weber CF. [Update on point-of-care-based coagulation treatment : Systems, reagents, device-specific treatment algorithms]. DIE ANAESTHESIOLOGIE 2024; 73:110-123. [PMID: 38261018 PMCID: PMC10850202 DOI: 10.1007/s00101-023-01368-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 01/24/2024]
Abstract
Viscoelastic test (VET) procedures suitable for point-of-care (POC) testing are in widespread clinical use. Due to the expanded range of available devices and in particular due to the development of new test approaches and methods, the authors believe that an update of the current treatment algorithms is necessary. The aim of this article is to provide an overview of the currently available VET devices and the associated reagents. In addition, two treatment algorithms for the VET devices most commonly used in German-speaking countries are presented.
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Affiliation(s)
- Felix C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Herbert Schöchl
- Ludwig Boltzmann Institut für Traumatologie, AUVA Research Center, Wien, Österreich
- Klinik für Anästhesiologie und Intensivmedizin, AUVA Unfallkrankenhaus, Salzburg, Österreich
| | - Kathrin Brün
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Sascha Kreuer
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
- Medizinische Fakultät, Universität des Saarlandes, Homburg, Deutschland
| | - Sven Schneider
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Stefan Hofer
- Klinik für Anästhesiologie, Westpfalz-Klinikum Kaiserslautern, Kaiserslautern, Deutschland
| | - Christian F Weber
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Klinik Wandsbek, Hamburg, Deutschland
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
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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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Barrett L, Curry N, Abu-Hanna J. Experimental Models of Traumatic Injuries: Do They Capture the Coagulopathy and Underlying Endotheliopathy Induced by Human Trauma? Int J Mol Sci 2023; 24:11174. [PMID: 37446351 PMCID: PMC10343021 DOI: 10.3390/ijms241311174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
Trauma-induced coagulopathy (TIC) is a major cause of morbidity and mortality in patients with traumatic injury. It describes the spectrum of coagulation abnormalities that occur because of the trauma itself and the body's response to the trauma. These coagulation abnormalities range from hypocoagulability and hyperfibrinolysis, resulting in potentially fatal bleeding, in the early stages of trauma to hypercoagulability, leading to widespread clot formation, in the later stages. Pathological changes in the vascular endothelium and its regulation of haemostasis, a phenomenon known as the endotheliopathy of trauma (EoT), are thought to underlie TIC. Our understanding of EoT and its contribution to TIC remains in its infancy largely due to the scarcity of experimental research. This review discusses the mechanisms employed by the vascular endothelium to regulate haemostasis and their dysregulation following traumatic injury before providing an overview of the available experimental in vitro and in vivo models of trauma and their applicability for the study of the EoT and its contribution to TIC.
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Affiliation(s)
- Liam Barrett
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge CB2 1TN, UK;
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Nicola Curry
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK;
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LD, UK
| | - Jeries Abu-Hanna
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK;
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Microcirculatory effects of rewarming in experimental hemorrhagic shock. Microvasc Res 2023; 147:104490. [PMID: 36736659 DOI: 10.1016/j.mvr.2023.104490] [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: 10/25/2022] [Revised: 01/15/2023] [Accepted: 01/23/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rewarming is a recommended therapy during the resuscitation of hypothermic patients with hemorrhagic shock. In experimental models, however, it increases inflammatory response and mortality. Although microcirculation is potential target of inflammation, the microvascular effects of rewarming during the resuscitation of hemorrhagic shock have not been studied. Our goal was to assess the systemic and microcirculatory effects of an increase in core temperature (T°) during the retransfusion of hemorrhagic shock in sheep. Our hypothesis was that rewarming could hamper microcirculation. METHODS In anesthetized and mechanically ventilated sheep, we measured systemic, intestinal, and renal hemodynamics and oxygen transport. O2 consumption (VO2) and respiratory quotient were measured by indirect calorimetry. Cortical renal, intestinal villi and sublingual microcirculation were assessed by IDF-videomicroscopy. After basal measurements, hemorrhagic shock was induced and T° was reduced to ~33 °C. After 1 h of shock and hypothermia, blood was retransfused and Ringer lactate solution was administered to prevent arterial hypotension. In the control group (n = 12), T° was not modified, while in the intervention (rewarming) group, it was elevated ~3 °C. Measurements were repeated after 1 h. RESULTS During shock, both groups showed similar systemic and microvascular derangements. After retransfusion, VO2 remained decreased compared to baseline in both groups, but was lower in the control compared to the rewarming group. Perfused vascular density has a similar behavior in both groups. Compared to baseline, it remained reduced in peritubular (control vs. rewarming group, 13.8 [8.7-17.5] vs. 15.7 [10.1-17.9] mm/mm2, PNS) and villi capillaries (14.7 [13.6-16.8] vs. 16.3 [14.2-16.9] mm/mm2, PNS), and normalized in sublingual mucosa (19.1 [16.0-20.3] vs. 16.6 [14.7-17.2] mm/mm2, PNS). CONCLUSIONS This is the first experimental study assessing the effect of rewarming on systemic, regional, and microcirculatory perfusion in hypothermic hemorrhagic shock. We found that a 3 °C increase in T° neither improved nor impaired the microvascular alterations that persisted after retransfusion. In addition, sublingual mucosa was less susceptible to reperfusion injury than villi and renal microcirculation.
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Franz C, Bender L, Dorn C, Sichtermann T, Minkenberg J, Franko M, Wiesmann M, Stockero A, Nikoubashman O, May R, Ridwan H. Platelet function testing using the Multiplate analyzer after administration of aspirin in Aachen minipigs. PLoS One 2022; 17:e0275756. [PMID: 36256639 PMCID: PMC9578582 DOI: 10.1371/journal.pone.0275756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
Knowledge of platelet function in pigs and the effectiveness of antiplatelet therapy is important to ensure proper transferability from animal studies to humans. Our aim was to (1) characterize baseline platelet function of Aachen minipigs using the bedside Multiplate analyzer, (2) compare baseline platelet function with Göttingen minipigs, and (3) characterize platelet inhibition within the first 5 minutes after intravenous administration of acetylsalicylic acid (ASA). We characterized the baseline platelet function and hematological parameters in 9 Aachen minipigs. Historical data of 8 unmedicated Göttingen minipigs were used for comparison of baseline values. Platelet inhibition in Aachen minipigs was tested 1-5 minutes after intravenous administration of 500 mg ASA. Multiplate examinations included the following tests: ASPI test (to assess the effect of ASA), adenosine-diphosphate-test (ADP test) and thrombin receptor activating peptide test (TRAP test). Median values and interquartile range (IQR) of the Multiplate baseline tests in Aachen minipigs were as follows: ASPI: 39 U (IQR = 21-71), ADP: 70 U (IQR = 48-73), and TRAP: 8 U (IQR = 6-9), whereas the values in Göttingen minipigs were as follows: ASPI: 70.5 U (IQR = 60-78), ADP: 51 U (IQR = 45-66), and TRAP: 6.5 U (IQR = 4-8). ASPI values of Göttingen minipigs were significantly higher than those of Aachen minipigs (p = 0.046). Intravenous administration of ASA in Aachen minipigs resulted in significant platelet inhibition after 1 minute, which remained stable over a period of 5 minutes (p≤0.038). Aachen minipigs appeared to have a high variance in arachidonic acid-mediated platelet aggregation. In Aachen minipigs, intravenous ASA administration resulted in immediate platelet inhibition.
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Affiliation(s)
- Christiane Franz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Lara Bender
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christoph Dorn
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Thorsten Sichtermann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Minkenberg
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Maximilian Franko
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Andrea Stockero
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rebecca May
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
- * E-mail:
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Dahlquist A, Elander Degerstedt L, von Oelreich E, Brännström A, Gustavsson J, P Arborelius U, Günther M. Blast polytrauma with hemodynamic shock, hypothermia, hypoventilation and systemic inflammatory response: description of a new porcine model. Eur J Trauma Emerg Surg 2022; 48:401-409. [PMID: 32862315 PMCID: PMC7456397 DOI: 10.1007/s00068-020-01476-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 08/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE In the past decade blast injuries have become more prevalent. Blast trauma may cause extensive injuries requiring improved early resuscitation and prevention of haemorrhage. Randomized prospective trials are logistically and ethically challenging, and large animal models are important for further research efforts. Few severe blast trauma models have been described, which is why we aimed to establish a comprehensive polytrauma model in accordance with the criteria of the Berlin definition of polytrauma and with a survival time of > 2 h. Multiple blast injuries to the groin and abdomen were combined with hypoperfusion, respiratory and metabolic acidosis, hypoventilation, hypothermia and inflammatory response. The model was compared to lung contusion and haemorrhage. METHODS 16 landrace swine (mean weight 60.5 kg) were randomized to "control" (n = 5), "chest trauma/hem" by lung contusion and class II haemorrhage (n = 5), and "blast polytrauma" caused by multiple blast injuries to the groin and abdomen, class II haemorrhage, lipopolysaccharide (LPS) infusion and hypothermia 32 °C (n = 6). RESULTS The blast polytrauma group had an Injury Severity Score of 57 which resulted in haemodynamic shock, hypothermia, respiratory and metabolic acidosis and inflammatory response. The chest trauma/hem group had an Injury Severity Score of 9 and less profound physiologic effects. Physiologic parameters presented a dose-response relationship corresponding to the trauma levels. CONCLUSION A comprehensive blast polytrauma model fulfilling the Berlin polytrauma criteria, with a high trauma load and a survival time of > 2 h was established. A severe, but consistent, injury profile was accomplished enabling the addition of experimental interventions in future studies, particularly of immediate resuscitation efforts including whole blood administration, trauma packing and haemostasis.
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Affiliation(s)
- Albin Dahlquist
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Louise Elander Degerstedt
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Erik von Oelreich
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Brännström
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ulf P Arborelius
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden.
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Tisherman SA. Emergency preservation and resuscitation for cardiac arrest from trauma. Ann N Y Acad Sci 2021; 1509:5-11. [PMID: 34859446 DOI: 10.1111/nyas.14725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/19/2021] [Accepted: 10/22/2021] [Indexed: 01/01/2023]
Abstract
Patients who suffer a cardiac arrest from trauma rarely survive. Surgical control of hemorrhage cannot be obtained in time to prevent irreversible organ damage. Emergency preservation and resuscitation (EPR) was developed to utilize hypothermia to buy time to achieve hemostasis and allow delayed resuscitation. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10 °C during exsanguination cardiac arrest can allow up to 2 h of circulatory arrest and repair of simulated injuries with normal neurologic recovery. The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT) trial is testing the feasibility and safety of initiating EPR. Study subjects include patients with penetrating trauma who lose a pulse within 5 minutes of hospital arrival and remain pulseless despite standard care. EPR is initiated via an intra-aortic flush of ice-cold saline solution. Following hemostasis, delayed resuscitation and rewarming are accomplished with cardiopulmonary bypass. The primary outcome is survival to hospital discharge without significant neurologic deficits. If trained team members are available, subjects can undergo EPR. If not, subjects can be enrolled as concurrent controls. Ten EPR and 10 control subjects will be enrolled. If successful, EPR could save the lives of trauma patients who are currently dying from exsanguinating hemorrhage.
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Affiliation(s)
- Samuel A Tisherman
- Department of Surgery and the Program in Trauma, University of Maryland School of Medicine, RA Cowley Shock Trauma Center, Baltimore, Maryland
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Maisha N, Rubenstein M, Bieberich CJ, Lavik E. Getting to the Core of It All: Nanocapsules to Mitigate Infusion Reactions Can Promote Hemostasis and Be a Platform for Intravenous Therapies. NANO LETTERS 2021; 21:9069-9076. [PMID: 34714087 DOI: 10.1021/acs.nanolett.1c02746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
One of the significant challenges to translation of intravenously administered nanomaterials has been complement-mediated infusion reactions which can be lethal. Slow infusions can reduce infusion reactions, but slow infusions are not always possible in applications like controlling bleeding following trauma. Thus, avoiding complement activation and infusion responses is essential to manage bleeding. We identified nanocapsules based on polyurethane as candidates that did not activate C5a and explored their PEGylation and functionalization with the GRGDS peptide to create a new class of hemostatic nanomaterials. Using the clinically relevant rotational thromboelastography (ROTEM), we determined that nanocapsules promote faster clotting than controls and maintain the maximum clot firmness, which is critical for reducing bleeding. Excitingly, these polyurethane-based nanocapsules did not activate complement or the major pro-inflammatory cytokines. This work provides critical evidence for the role of modulating the core material in developing safer nanomedicines for intravenous applications.
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Affiliation(s)
- Nuzhat Maisha
- University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Michael Rubenstein
- University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Charles J Bieberich
- University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Erin Lavik
- University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
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10
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Brännström A, von Oelreich E, Degerstedt LE, Dahlquist A, Hånell A, Gustavsson J, Günther M. The swine as a vehicle for research in trauma-induced coagulopathy: Introducing principal component analysis for viscoelastic coagulation tests. J Trauma Acute Care Surg 2021; 90:360-368. [PMID: 33093294 DOI: 10.1097/ta.0000000000002997] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Uncontrolled bleeding is the leading cause of potentially preventable deaths among trauma patients. Tissue injury and shock result in trauma-induced coagulopathy (TIC). There are still uncertainties regarding detection methods and best practice management for TIC, and a deeper understanding of the pathophysiology requires robust animal models. The applicability of swine in coagulation studies, particularly after trauma has not been sufficiently elucidated. We, therefore, evaluated the swine as a vehicle for TIC research in a selection of trauma modalities. METHODS Twenty-six landrace swine (3 females/23 males) (mean weight, 60.0 kg) were anesthetized and randomized to negative controls, receiving no manipulation (n = 5), positive controls by hemodilution (n = 5), pulmonary contusion without hemorrhage (n = 5), pulmonary contusion with hemorrhage (n = 5), and blast polytrauma with hypothermia, hypoperfusion, hypoventilation, and systemic inflammation (n = 6). A comprehensive coagulation panel was analyzed at baseline, 20 minutes and 120 minutes after trauma. RESULTS PT(INR), aPTT, thrombocytes, and fibrinogen did not change after trauma. D-dimer increased (p < 0.0001), prothrombin decreased (p < 0.05) and aPC decreased (p < 0.01) after polytrauma. PAI-1 decreased after pulmonary contusion with hemorrhage (p < 0.05). Positive controls displayed changes in PT(INR), thrombocytes, fibrinogen, prothrombin, aPC (p < 0.05). Principal Component Analysis of rotational thromboelastometry presented pathologic coagulation profiles in both polytrauma and positive control groups with vectors extending outside the 95% confidence interval, which were not detected in negative controls. CONCLUSION Coagulopathy was induced after severe porcine blast polytrauma, specifically detected in rotational thromboelastometry. A novel method for principal component analysis of viscoelastic tests was introduced which may increase the detection sensitivity and differentiation of TIC phenotypes and should be further investigated in trauma populations.
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Affiliation(s)
- Andreas Brännström
- From the Department of Clinical Science and Education (A.B., L.E.D., A.D., M.G.), Department of Physiology and Pharmacology (E.v.O.), and Department of Neuroscience (A.H., J.G.), Karolinska Institutet, Stockholm, Sweden
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11
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Haffner-Luntzer M, Hankenson KD, Ignatius A, Pfeifer R, Khader BA, Hildebrand F, van Griensven M, Pape HC, Lehmicke M. Review of Animal Models of Comorbidities in Fracture-Healing Research. J Orthop Res 2019; 37:2491-2498. [PMID: 31444806 DOI: 10.1002/jor.24454] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/13/2019] [Indexed: 02/04/2023]
Abstract
There is clinical evidence that patient-specific comorbidities like osteoporosis, concomitant tissue injury, and ischemia may strongly interfere with bone regeneration. However, underlying mechanisms are still unclear. To study these mechanisms in detail, appropriate animal models are needed. For decades, bone healing has been studied in large animals, including dogs, rabbits, pigs, or sheep. However, large animal models display a limited ability to study molecular pathways and cellular functions. Therefore in recent years, mice and rats have become increasingly popular as a model organism for fracture healing research due to the availability of molecular analysis tools and transgenic models. Both large and small animals can be used to study comorbidities and risk factors, modelling the human clinical situation. However, attention has to be paid when choosing an appropriate model due to species differences between large animals, rodents, and humans. This review focuses on large and small animal models for the common comorbidities ischemic injury/reduced vascularization, osteoporosis, and polytrauma, and critically discusses the translational and molecular aspects of these models. Here, we review material which was presented at the workshop "Animal Models of Comorbidities in Fracture Healing Research" at the 2019 ORS Annual Meeting in Austin Texas. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2491-2498, 2019.
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Affiliation(s)
- Melanie Haffner-Luntzer
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Kurt D Hankenson
- Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Basel A Khader
- Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Frank Hildebrand
- Department of Orthopaedic Trauma, University Hospital RWTH Aachen, Aachen, Germany
| | - Martijn van Griensven
- Department of Experimental Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Michael Lehmicke
- Alliance for Regenerative Medicine, Washington, District of Columbia
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12
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Platelet function testing in pigs using the Multiplate® Analyzer. PLoS One 2019; 14:e0222010. [PMID: 31465489 PMCID: PMC6715187 DOI: 10.1371/journal.pone.0222010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 08/20/2019] [Indexed: 01/02/2023] Open
Abstract
For endovascular research pigs are an established animal model. However, experiences regarding analyses of platelet inhibition in pigs using the Multiplate® Analyzer are limited. The aims of the present study were to investigate if (1) the Multiplate® Analyzer is a suitable method for examination of porcine platelet function using manufacturers’ recommendations for human blood, and (2) platelet inhibition can be induced with acetylsalicylic acid (ASA) and clopidogrel in pigs reliably, and if (3) non-responders to one of the drug can be detected. Additionally we examined differences in (4) the effectiveness of ASA between oral administration and intravenous application, and (5) between domestic pigs (German Landrace; GL) and miniature pigs (MP). We investigated platelet function of 36 unmedicated pigs (GL n = 28; MP n = 8). In addition, 32 blood samples taken from medicated pigs (GL n = 15; MP n = 17) were analysed. Platelet inhibition was induced in four different ways: (1) 500 mg ASA intravenously (n = 11), (2) 500 mg ASA intravenously and 450 mg clopidogrel orally (n = 5), (3) 250 mg ASA orally (n = 11), (4) 250 mg ASA orally and 75 mg clopidogrel orally (n = 5). Results of the ASPI and ADP test of the Multiplate® Analyzer subtests in unmedicated and medicated pigs were in a comparable range to results known from humans. Application of ASA decreased the mean values of the ASPI test significantly regardless of the application method. Joined administration of ASA and clopidogrel also decreased the mean values of the ADP test significantly. Both, oral and intravenous administrations of ASA as well as oral administration of clopidogrel effectively inhibited platelet function in pigs. One pig did not respond to clopidogrel. We found no differences between domestic and miniature pigs regarding reference values in unmedicated pigs and the effectiveness of ASA and clopidogrel.
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Sun YJ, Zhang ZY, Fan B, Li GY. Neuroprotection by Therapeutic Hypothermia. Front Neurosci 2019; 13:586. [PMID: 31244597 PMCID: PMC6579927 DOI: 10.3389/fnins.2019.00586] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022] Open
Abstract
Hypothermia therapy is an old and important method of neuroprotection. Until now, many neurological diseases such as stroke, traumatic brain injury, intracranial pressure elevation, subarachnoid hemorrhage, spinal cord injury, hepatic encephalopathy, and neonatal peripartum encephalopathy have proven to be suppressed by therapeutic hypothermia. Beneficial effects of therapeutic hypothermia have also been discovered, and progress has been made toward improving the benefits of therapeutic hypothermia further through combination with other neuroprotective treatments and by probing the mechanism of hypothermia neuroprotection. In this review, we compare different hypothermia induction methods and provide a summarized account of the synergistic effect of hypothermia therapy with other neuroprotective treatments, along with an overview of hypothermia neuroprotection mechanisms and cold/hypothermia-induced proteins.
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Affiliation(s)
- Ying-Jian Sun
- Department of Ophthalmology, The Second Hospital of Jilin University, Changchun, China
| | - Zi-Yuan Zhang
- Department of Ophthalmology, The Second Hospital of Jilin University, Changchun, China
| | - Bin Fan
- Department of Ophthalmology, The Second Hospital of Jilin University, Changchun, China
| | - Guang-Yu Li
- Department of Ophthalmology, The Second Hospital of Jilin University, Changchun, China
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Kander T, Ullén S, Dankiewicz J, Wise MP, Schött U, Rundgren M. Bleeding Complications After Cardiac Arrest and Targeted Temperature Management, a Post Hoc Study of the Targeted Temperature Management Trial. Ther Hypothermia Temp Manag 2018; 9:177-183. [PMID: 30523732 DOI: 10.1089/ther.2018.0024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Target Temperature Management (TTM) is standard care following out of hospital cardiac arrest (OHCA). The aim of the study was to evaluate if treatment temperature (33°C or 36°C) or other predefined variables were associated with the occurrence of bleeding in the TTM study. This study is a predefined, post hoc analysis of the TTM trial, a multinational randomized controlled trial comparing treatment at 33°C and 36°C for 24 hours after OHCA with return of spontaneous circulation. Bleeding events from several locations were registered daily. The main outcome measure was occurrence of any bleeding during the first 3 days of intensive care. Risk factors for bleeding, including temperature allocation, were evaluated. Complete data were available for 722/939 patients. Temperature allocation was not associated with bleeding either in the univariable (p = 0.95) or in the primary multivariable analysis (odds ratio [OR] 0.95; 95% confidence interval [CI] 0.64-1.41, p = 0.80). A multiple imputation model, including all patients, was used as a sensitivity analysis, rendering similar results (OR 0.98; 95% CI 0.69-1.38, p = 0.92). Factors associated with bleeding were increasing age, female sex, and angiography with percutaneous coronary intervention (PCI) within 36 hours of cardiac arrest (CA) in both the primary and the sensitivity analysis. TTM at 33°C, when compared to TTM at 36°C, was not associated with an increased incidence of bleeding during the first 3 days of intensive care after CA. Increasing age, female gender, and PCI were independently associated with any bleeding the first 3 days after CA.
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Affiliation(s)
- Thomas Kander
- Department of Clinical Sciences, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Susann Ullén
- Clinical Studies Sweden-Forum South Skane University Hospital, Lund, Sweden
| | - Josef Dankiewicz
- Department of Cardiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Ulf Schött
- Department of Clinical Sciences, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Malin Rundgren
- Department of Clinical Sciences, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
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Eschbach D, Horst K, Sassen M, Andruszkow J, Mohr J, Debus F, Vogt N, Steinfeldt T, Hildebrand F, Schöller K, Uhl E, Wulf H, Ruchholtz S, Pape H, Frink M. Hypothermia does not influence liver damage and function in a porcine polytrauma model. Technol Health Care 2018; 26:209-221. [PMID: 28968251 DOI: 10.3233/thc-171043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies revealed evidence that induced hypothermia attenuates ischemic organ injuries after severe trauma. In the present study, the effect of hypothermia on liver damage was investigated in a porcine long term model of multi-system injury, consisting of blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shockMETHODS: In 30 pigs, a standardized polytrauma including blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shock of 45% of total blood volume was induced. Following trauma, hypothermia of 33∘C was induced for 12 h and intensive care treatment was evaluated for 48 h. As outcome parameters, we assessed liver function and serum transaminase levels as well as a histopathological analysis of tissue samples. A further 10 animals served as controls. RESULTS Serum transaminase levels were increased at the end of the observation period following hypothermia without reaching statistical significance compared to normothermic groups. Liver function was preserved (p⩽ 0.05) after the rewarming period in hypothermic animals but showed no difference at the end of the observation period. In H&E staining, cell death was slightly increased hypothermic animals and caspase-3 staining displayed tendency towards more apoptosis in hypothermic group as well. CONCLUSIONS Induction of hypothermia could not significantly improve hepatic damage during the first 48 h following major trauma. Further studies focusing on multi-organ failure including a longer observation period are required to illuminate the impact of hypothermia on hepatic function in multiple trauma patients.
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Affiliation(s)
- D Eschbach
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - K Horst
- Trauma Department, University of Aachen, Aachen, Germany
| | - M Sassen
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - J Andruszkow
- Institute of Pathology, University of Aachen, Aachen, Germany
| | - J Mohr
- Department of Trauma Surgery, University of Magdeburg, Magdeburg, Germany
| | - F Debus
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - N Vogt
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - T Steinfeldt
- Department of Anesthesiology and Critical Care, Diakonie-Klinikum Schwäbisch Hall, Germany
| | - F Hildebrand
- Trauma Department, University of Aachen, Aachen, Germany
| | - K Schöller
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - E Uhl
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - H Wulf
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - S Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - H Pape
- Department of Trauma, University of Zurich, Zurich, Switzerland
| | - M Frink
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
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Hsieh TM, Kuo PJ, Hsu SY, Chien PC, Hsieh HY, Hsieh CH. Effect of Hypothermia in the Emergency Department on the Outcome of Trauma Patients: A Cross-Sectional Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15081769. [PMID: 30126107 PMCID: PMC6121888 DOI: 10.3390/ijerph15081769] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/31/2018] [Accepted: 08/11/2018] [Indexed: 11/21/2022]
Abstract
This study aimed to assess whether hypothermia is an independent predictor of mortality in trauma patients in the condition of defining hypothermia as body temperatures of <36 °C. Data of all hospitalized adult trauma patients recorded in the Trauma Registry System at a level I trauma center between 1 January 2009 and 12 December 2015 were retrospectively reviewed. A multivariate logistic regression analysis was performed in order to identify factors related to mortality. In addition, hypothermia and normothermia were defined as temperatures <36 °C and from 36 °C to 38 °C, respectively. Propensity score-matched study groups of hypothermia and normothermia patients in a 1:1 ratio were grouped for mortality assessment after adjusting for potential confounders such as age, sex, preexisting comorbidities, and injury severity score (ISS). Of 23,705 enrolled patients, a total of 401 hypothermic patients and 13,368 normothermic patients were included in this study. Only 3.0% of patients had hypothermia upon arrival at the emergency department (ED). Compared to normothermic patients, hypothermic patients had a significantly higher rate of abbreviated injury scale (AIS) scores of ≥3 in the head/neck, thorax, and abdomen and higher ISS. The mortality rate in hypothermic patients was significantly higher than that in normothermic patients (13.5% vs. 2.3%, odds ratio (OR): 6.6, 95% confidence interval (CI): 4.86–9.01, p < 0.001). Of the 399 well-balanced propensity score-matched pairs, there was no significant difference in mortality (13.0% vs. 9.3%, OR: 1.5, 95% CI: 0.94–2.29, p = 0.115). However, multivariate logistic regression analysis revealed that patients with low body temperature were significantly associated with the mortality outcome. This study revealed that low body temperature is associated with the mortality outcome in the multivariate logistic regression analysis but not in the propensity score matching (PSM) model that compared patients with hypothermia defined as body temperatures of <36 °C to those who had normothermia. These contradicting observations indicated the limitation of the traditional definition of body temperature for the diagnosis of hypothermia. Prospective randomized control trials are needed to determine the relationship between hypothermia following trauma and the clinical outcome.
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Affiliation(s)
- Ting-Min Hsieh
- Division of Trauma Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Pao-Jen Kuo
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Shiun-Yuan Hsu
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Peng-Chen Chien
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Hsiao-Yun Hsieh
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Ching-Hua Hsieh
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
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Caspers M, Schäfer N, Fröhlich M, Bauerfeind U, Bouillon B, Mutschler M, Maegele M. How do external factors contribute to the hypocoagulative state in trauma-induced coagulopathy? - In vitro analysis of the lethal triad in trauma. Scand J Trauma Resusc Emerg Med 2018; 26:66. [PMID: 30111342 PMCID: PMC6094881 DOI: 10.1186/s13049-018-0536-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 08/06/2018] [Indexed: 11/18/2022] Open
Abstract
Background External factors following trauma and iatrogenic intervention influence blood coagulation and particularly clot formation. In particular, three external factors (in detail dilution via uncritical volume replacement, acidosis and hypothermia), in combination, referred to as the “lethal triad”, substantially aggravate the hypocoagulative state after trauma. Contribution of these external factors to the resulting hypocoagulative state in trauma and especially their influence on primary haemostasis has still not been investigated systematically. This study aims to assess this contribution to the aggravating hypocoagulative state in trauma-induced coagulopathy (TIC) using an in vitro simulation assay. Emphasis is given to platelet contribution to clot formation and to the investigation of how platelet activation alters under the respective conditions. Methods To simulate the conditions of lethal triad in vitro, whole blood samples taken from five healthy volunteers were introduced to the respective conditions. Besides standard coagulation testing, thrombelastometric analysis and differentiated platelet mapping were performed. Results All three simulated conditions induced significant impairments of clot formation (clot formation time, CFT; α -angle) and propagation (maximum clot firmness, MCF; Diameter A5-A25), with the highest impact under hypothermia and dilution. Consistently, lethal triad resulted in an additive effect of all conditions. None of the simulated conditions induced a statistically relevant change in coagulation initiation assessed by EXTEM and FIBTEM thrombelastometry. Platelet contribution to clot formation decreased gradually under the respective conditions, reaching statistical significance for simulated dilution, and attaining its greatest extent under the conditions of lethal triad (Δtrias/baseline 0.59; p = 0.01). Consistent, reduced CD62 expression levels were observed under experimental acidosis (Δacidosis/baseline 0.32; p = 0.006), dilution (Δdilution/baseline 0.34; p = 0.01) and lethal triad (Δlethal triad/baseline 0.24; p = 0.01). Conclusion The respective external factors of lethal triad play a pivotal role in the development of coagulopathy, essentially influencing the kinetics of clot formation, and to a varying extent clot diameter, as measured by thrombelastometry. Moreover, impairment of platelet function under the conditions of lethal triad plays a key role in the pathophysiology of TIC, resulting in reduced responsiveness to stimulation with ADP that might also be present after trauma. Our data indicate that impairment of primary haemostasis contribute to the hypocoagulative state in TIC after trauma aggravated by external factors of lethal triad.
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Affiliation(s)
- Michael Caspers
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany. .,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - Nadine Schäfer
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Matthias Fröhlich
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Ursula Bauerfeind
- Department of Transfusion Medicine, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne- Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Bertil Bouillon
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Manuel Mutschler
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Marc Maegele
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany.,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
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A clinically relevant and bias-controlled murine model to study acute traumatic coagulopathy. Sci Rep 2018; 8:5783. [PMID: 29636535 PMCID: PMC5893580 DOI: 10.1038/s41598-018-24225-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 03/20/2018] [Indexed: 12/30/2022] Open
Abstract
Acute traumatic coagulopathy (ATC) is an acute and endogenous mechanism triggered by the association of trauma and hemorrhage. Several animal models have been developed, but some major biases have not yet been identified. Our aim was to develop a robust and clinically relevant murine model to study this condition. Anesthetized adult Sprague Dawley rats were randomized into 4 groups: C, control; T, trauma; H, hemorrhage; TH, trauma and hemorrhage (n = 7 each). Trauma consisted of laparotomy associated with four-limb and splenic fractures. Clinical variables, ionograms, arterial and hemostasis blood tests were compared at 0 and 90 min. ATC and un-compensated shock were observed in group TH. In this group, the rise in prothrombin time and activated partial thromboplastin was 29 and 40%, respectively. Shock markers, compensation mechanisms and coagulation pathways were all consistent with human pathophysiology. The absence of confounding factors, such as trauma-related bleeding or dilution due to trans-capillary refill was verified. This ethic, cost effective and bias-controlled model reproduced the specific and endogenous mechanism of ATC and will allow to identify potential targets for therapeutics in case of trauma-related hemorrhage.
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19
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Modeling Acute Traumatic Hemorrhagic Shock Injury: Challenges and Guidelines for Preclinical Studies. Shock 2017; 48:610-623. [DOI: 10.1097/shk.0000000000000901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Aléx J, Uppstu T, Saveman BI. The opinions of ambulance personnel regarding using a heated mattress for patients being cared for in a cold climate - An intervention study in ambulance care. Int J Circumpolar Health 2017; 76:1379305. [PMID: 28990464 PMCID: PMC5645772 DOI: 10.1080/22423982.2017.1379305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purpose of the study was to describe the opinions of ambulance personnel regarding differences between using a heated mattress and a standard ambulance mattress. This study was an intervention study with pre- and post-evaluation. Evaluations of the opinions of personnel regarding the standard unheated mattress were conducted initially. After the intervention with new heated mattresses, follow-up evaluations were conducted. Ambulance personnel (n=64) from an ambulance station in northern Sweden took part in the study, which ran from October 2014 until February 2016. There were differences in opinions regarding the standard unheated mattress and the new heated mattress. The evaluation of the proxy ratings by the personnel showed that the heated mattress was warmer than the standard mattress, more pleasant to lie on and that patients were happier and more relaxed than when the standard mattress was used. The ambulance personnel in this study rated the experience of working with the heated mattress as very positive and proxy rated that it had a good effect on patient comfort. A heated mattress can be recommended for patients in ambulance care, even if more research is needed to receive sufficient evidence.
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Affiliation(s)
- Jonas Aléx
- a Department of Nursing and affiliated with the Arctic Research Centre at Umeå University, Research fields: Prehospital emergency care , Umeå University , Umeå , Sweden
| | - Tom Uppstu
- b Department of Nursing , Umeå University , Umeå , Sweden
| | - Britt-Inger Saveman
- a Department of Nursing and affiliated with the Arctic Research Centre at Umeå University, Research fields: Prehospital emergency care , Umeå University , Umeå , Sweden
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21
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Prolonged TTM – enhanced hypocoagulation and bleeding? Resuscitation 2017; 118:A3-A4. [DOI: 10.1016/j.resuscitation.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/01/2017] [Indexed: 11/19/2022]
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22
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Blood biochemical changes in pigs after infusion with acetate-buffered or lactate-buffered crystalloid solutions. Lab Anim (NY) 2016; 44:268-73. [PMID: 26091132 DOI: 10.1038/laban.739] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/18/2014] [Indexed: 01/15/2023]
Abstract
Perioperative fluid therapy is an important component of many medical procedures with animals. Buffered crystalloid solutions avoid inducing metabolic acidosis, but lactated solutions can elevate blood lactate concentrations and acetated solutions have not been thoroughly investigated using large animals. Here, the authors compare blood biochemical parameters in 20 juvenile pigs after perioperative fluid administration of an acetate-buffered solution (Elo-Mel isoton, EMI) or a lactate-buffered solution (lactated Ringer's solution, LRS). The authors measured blood lactate, glucose and electrolyte concentrations before and after administering the test fluid during surgery. Blood lactate concentration after administration was significantly higher in pigs that received LRS than in pigs that received EMI, but glucose and electrolyte concentrations did not differ significantly between treatment groups before or after administration. These findings suggest that EMI might be a preferable option for perioperative fluid therapy in pigs.
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23
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Jensen KO, Held L, Kraus A, Hildebrand F, Mommsen P, Mica L, Wanner GA, Steiger P, Moos RM, Simmen HP, Sprengel K. The impact of mild induced hypothermia on the rate of transfusion and the mortality in severely injured patients: a retrospective multi-centre study. Eur J Med Res 2016; 21:37. [PMID: 27716419 PMCID: PMC5052900 DOI: 10.1186/s40001-016-0233-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although under discussion, induced hypothermia (IH) is an established therapy for patients with cardiac arrest or traumatic brain injuries. The influences on coagulopathy and bleeding tendency in severely injured patients (SIP) with concomitant traumatic brain injury are most widely unclear. Therefore, the aim of this study was to quantify the effect of mild IH in SIP with concomitant severe traumatic brain injuries on transfusion rate and mortality. METHODS In this retrospective multi-centre study, SIP from three European level-1 trauma centres with an ISS ≥16 between 2009 and 2011 were included. At hospital A, patients qualified for IH with age ≤70 years and a severe head injury with an abbreviated injury scale (AISHead) of ≥3. IH was defined as target core body temperature of 35 °C. Hypothermic patients were matched with two patients, one from hospital B and one from hospital C using age and AISHead. The effect of IH on the transfusion rate, complications and mortality was quantified with 95 % confidence intervals (CI). Patients not treated with IH in hospital A and those from hospital B and C, who were not matched, were used to adjust the CI for the effect of inter-hospital therapy protocol differences. RESULTS Mean age of patients in the IH-group (n = 43) was 35.7 years, mean ISS 30 points and sex distribution showed 83.7 % male. Mean age of matched patients in the normotherm-group (n = 86) was 36.7 years, mean ISS 33 points and there were 75.6 % males. For the hypothermic patients, we pointed out an estimate of mean difference for the number of transfused units of packed red blood cells as well as for mortality which does not indicate a decrease in the benefit gained by hypothermia. It is suggested that hypothermic patients tend to a higher rate of lung failure and thromboembolisms. CONCLUSION Though tending to an increased rate of complications, there is no evidence for a difference in both; rate of transfusion and mortality in SIP. Mild IH as an option for severe head injuries seems as well-being practicable in the presence of multiple severe injuries. Further, clinical studies regarding the side effects are necessary.
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Affiliation(s)
- Kai Oliver Jensen
- Division of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Leonhard Held
- Department of Biostatistics, Institute for Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland
| | - Andrea Kraus
- Department of Biostatistics, Institute for Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland
| | - Frank Hildebrand
- Department of Orthopedic Trauma, University of Aachen, Aachen, Germany
| | - Philipp Mommsen
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Ladislav Mica
- Division of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Guido A. Wanner
- Division of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Peter Steiger
- Division of Surgical Intensive Care Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Rudolf M. Moos
- University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hans-Peter Simmen
- Division of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Kai Sprengel
- Division of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Effects of Hyperoxia and Mild Therapeutic Hypothermia During Resuscitation From Porcine Hemorrhagic Shock. Crit Care Med 2016; 44:e264-77. [PMID: 26588829 DOI: 10.1097/ccm.0000000000001412] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Hemorrhagic shock-induced tissue hypoxia induces hyperinflammation, ultimately causing multiple organ failure. Hyperoxia and hypothermia can attenuate tissue hypoxia due to increased oxygen supply and decreased demand, respectively. Therefore, we tested the hypothesis whether mild therapeutic hypothermia and hyperoxia would attenuate postshock hyperinflammation and thereby organ dysfunction. DESIGN Prospective, controlled, randomized study. SETTING University animal research laboratory. SUBJECTS Thirty-six Bretoncelles-Meishan-Willebrand pigs of either gender. INTERVENTIONS After 4 hours of hemorrhagic shock (removal of 30% of the blood volume, subsequent titration of mean arterial pressure at 35 mm Hg), anesthetized and instrumented pigs were randomly assigned to "control" (standard resuscitation: retransfusion of shed blood, fluid resuscitation, norepinephrine titrated to maintain mean arterial pressure at preshock values, mechanical ventilation titrated to maintain arterial oxygen saturation > 90%), "hyperoxia" (standard resuscitation, but FIO2, 1.0), "hypothermia" (standard resuscitation, but core temperature 34°C), or "combi" (hyperoxia plus hypothermia) (n = 9 each). MEASUREMENTS AND MAIN RESULTS Before, immediately at the end of and 12 and 22 hours after hemorrhagic shock, we measured hemodynamics, blood gases, acid-base status, metabolism, organ function, cytokine production, and coagulation. Postmortem kidney specimen were taken for histological evaluation, immunohistochemistry (nitrotyrosine, cystathionine γ-lyase, activated caspase-3, and extravascular albumin), and immunoblotting (nuclear factor-κB, hypoxia-inducible factor-1α, heme oxygenase-1, inducible nitric oxide synthase, B-cell lymphoma-extra large, and protein expression of the endogenous nuclear factor-κB inhibitor). Although hyperoxia alone attenuated the postshock hyperinflammation and thereby tended to improve visceral organ function, hypothermia and combi treatment had no beneficial effect. CONCLUSIONS During resuscitation from near-lethal hemorrhagic shock, hyperoxia attenuated hyperinflammation, and thereby showed a favorable trend toward improved organ function. The lacking efficacy of hypothermia was most likely due to more pronounced barrier dysfunction with vascular leakage-induced circulatory failure.
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Long-Term Effects of Induced Hypothermia on Local and Systemic Inflammation - Results from a Porcine Long-Term Trauma Model. PLoS One 2016; 11:e0154788. [PMID: 27144532 PMCID: PMC4856279 DOI: 10.1371/journal.pone.0154788] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 04/19/2016] [Indexed: 11/25/2022] Open
Abstract
Background Hypothermia has been discussed as playing a role in improving the early phase of systemic inflammation. However, information on the impact of hypothermia on the local inflammatory response is sparse. We therefore investigated the kinetics of local and systemic inflammation in the late posttraumatic phase after induction of hypothermia in an established porcine long-term model of combined trauma. Materials & Methods Male pigs (35 ± 5kg) were mechanically ventilated and monitored over the study period of 48 h. Combined trauma included tibia fracture, lung contusion, liver laceration and pressure-controlled hemorrhagic shock (MAP < 30 ± 5 mmHg for 90 min). After resuscitation, hypothermia (33°C) was induced for a period of 12 h (HT-T group) with subsequent re-warming over a period of 10 h. The NT-T group was kept normothermic. Systemic and local (fracture hematoma) cytokine levels (IL-6, -8, -10) and alarmins (HMGB1, HSP70) were measured via ELISA. Results Severe signs of shock as well as systemic and local increases of pro-inflammatory mediators were observed in both trauma groups. In general the local increase of pro- and anti-inflammatory mediator levels was significantly higher and prolonged compared to systemic concentrations. Induction of hypothermia resulted in a significantly prolonged elevation of both systemic and local HMGB1 levels at 48 h compared to the NT-T group. Correspondingly, local IL-6 levels demonstrated a significantly prolonged increase in the HT-T group at 48 h. Conclusion A prolonged inflammatory response might reduce the well-described protective effects on organ and immune function observed in the early phase after hypothermia induction. Furthermore, local immune response also seems to be affected. Future studies should aim to investigate the use of therapeutic hypothermia at different degrees and duration of application.
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The Use of Extracorporeal Membrane Oxygenation Systems in Severe Accidental Hypothermia After Drowning. ASAIO J 2016; 62:157-62. [DOI: 10.1097/mat.0000000000000312] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Stahl AR, Kurz MC, Dub L, Holzhausen JM, Sawyer KN. Limb-Threatening Acute Venous Thromboembolism in a Patient Undergoing Postarrest Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2015; 5:228-34. [DOI: 10.1089/ther.2015.0019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Amanda R. Stahl
- Oakland University William Beaumont School of Medicine, Rochester Hills, Michigan
| | - Michael C. Kurz
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Larissa Dub
- Department of Emergency Medicine, Osceola Regional Medical Center, Kissimmee, Florida
| | - Jenna M. Holzhausen
- Department of Pharmaceutical Services, William Beaumont Hospital, Royal Oak, Michigan
| | - Kelly N. Sawyer
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
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Induced Hypothermia Does Not Harm Hemodynamics after Polytrauma: A Porcine Model. Mediators Inflamm 2015; 2015:829195. [PMID: 26170533 PMCID: PMC4481088 DOI: 10.1155/2015/829195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The deterioration of hemodynamics instantly endangers the patients' life after polytrauma. As accidental hypothermia frequently occurs in polytrauma, therapeutic hypothermia still displays an ambivalent role as the impact on the cardiopulmonary function is not yet fully understood. METHODS We have previously established a porcine polytrauma model including blunt chest trauma, penetrating abdominal trauma, and hemorrhagic shock. Therapeutic hypothermia (34°C) was induced for 3 hours. We documented cardiovascular parameters and basic respiratory parameters. Pigs were euthanized after 15.5 hours. RESULTS Our polytrauma porcine model displayed sufficient trauma impact. Resuscitation showed adequate restoration of hemodynamics. Induced hypothermia had neither harmful nor major positive effects on the animals' hemodynamics. Though heart rate significantly decreased and mixed venous oxygen saturation significantly increased during therapeutic hypothermia. Mean arterial blood pressure, central venous pressure, pulmonary arterial pressure, and wedge pressure showed no significant differences comparing normothermic trauma and hypothermic trauma pigs during hypothermia. CONCLUSIONS Induced hypothermia after polytrauma is feasible. No major harmful effects on hemodynamics were observed. Therapeutic hypothermia revealed hints for tissue protective impact. But the chosen length for therapeutic hypothermia was too short. Nevertheless, therapeutic hypothermia might be a useful tool for intensive care after polytrauma. Future studies should extend therapeutic hypothermia.
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Han Z, Liu X, Luo Y, Ji X. Therapeutic hypothermia for stroke: Where to go? Exp Neurol 2015; 272:67-77. [PMID: 26057949 DOI: 10.1016/j.expneurol.2015.06.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/16/2015] [Accepted: 06/04/2015] [Indexed: 01/08/2023]
Abstract
Ischemic stroke is a major cause of death and long-term disability worldwide. Thrombolysis with recombinant tissue plasminogen activator is the only proven and effective treatment for acute ischemic stroke; however, therapeutic hypothermia is increasingly recognized as having a tissue-protective function and positively influencing neurological outcome, especially in cases of ischemia caused by cardiac arrest or hypoxic-ischemic encephalopathy in newborns. Yet, many aspects of hypothermia as a treatment for ischemic stroke remain unknown. Large-scale studies examining the effects of hypothermia on stroke are currently underway. This review discusses the mechanisms underlying the effect of hypothermia, as well as trends in hypothermia induction methods, methods for achieving optimal protection, side effects, and therapeutic strategies combining hypothermia with other neuroprotective treatments. Finally, outstanding issues that must be addressed before hypothermia treatment is implemented at a clinical level are also presented.
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Affiliation(s)
- Ziping Han
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiangrong Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China; Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China.
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Gu X, Wei ZZ, Espinera A, Lee JH, Ji X, Wei L, Dix TA, Yu SP. Pharmacologically induced hypothermia attenuates traumatic brain injury in neonatal rats. Exp Neurol 2015; 267:135-142. [PMID: 25725354 DOI: 10.1016/j.expneurol.2015.02.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/18/2015] [Accepted: 02/20/2015] [Indexed: 12/30/2022]
Abstract
Neonatal brain trauma is linked to higher risks of mortality and neurological disability. The use of mild to moderate hypothermia has shown promising potential against brain injuries induced by stroke and traumatic brain injury (TBI) in various experimental models and in clinical trials. Conventional methods of physical cooling, however, are difficult to use in acute treatments and in induction of regulated hypothermia. In addition, general anesthesia is usually required to mitigate the negative effects of shivering during physical cooling. Our recent investigations demonstrate the potential therapeutic benefits of pharmacologically induced hypothermia (PIH) using the neurotensin receptor (NTR) agonist HPI201 (formerly known as ABS201) in stroke and TBI models of adult rodents. The present investigation explored the brain protective effects of HPI201 in a P14 rat pediatric model of TBI induced by controlled cortical impact. When administered via intraperitoneal (i.p.) injection, HPI201 induced dose-dependent reduction of body and brain temperature. A 6-h hypothermic treatment, providing an overall 2-3°C reduction of brain and body temperature, showed significant effect of attenuating the contusion volume versus TBI controls. Attenuation occurs whether hypothermia is initiated 15min or 2h after TBI. No shivering response was seen in HPI201-treated animals. HPI201 treatment also reduced TUNEL-positive and TUNEL/NeuN-colabeled cells in the contusion area and peri-injury regions. TBI-induced blood-brain barrier damage was attenuated by HPI201 treatment, evaluated using the Evans Blue assay. HPI201 significantly decreased MMP-9 levels and caspase-3 activation, both of which are pro-apototic, while it increased anti-apoptotic Bcl-2 gene expression in the peri-contusion region. In addition, HPI201 prevented the up-regulation of pro-inflammatory tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and IL-6. In sensorimotor activity assessments, rats in the HPI201 treated group exhibited improved functional recovery after TBI versus controls. These data support that PIH therapy using our NTR agonist is effective in reducing neuronal and BBB damage, attenuating inflammatory response and detrimental cellular signaling, and promoting functional recovery after TBI in the developing brain, supporting its potential for further evaluation towards clinical development.
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Affiliation(s)
- Xiaohuan Gu
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Zheng Zachory Wei
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA.,Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, GA 30033, USA
| | - Alyssa Espinera
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jin Hwan Lee
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Xiaoya Ji
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Ling Wei
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Thomas A Dix
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.,JT Pharmaceuticals Inc, Mt. Pleasant, SC, 29464
| | - Shan Ping Yu
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA.,Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, GA 30033, USA
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Abstract
PURPOSE OF REVIEW Hemorrhage is the leading cause of potentially preventable death following injury. Excessive and uncontrolled bleeding, commonly referred to as trauma-induced coagulopathy (TIC), affects a quarter of all trauma patients and is associated with substantial injuries, increased transfusion requirements, and poor outcomes. Recent data have contributed to our current understanding of the molecular mechanisms driving TIC. RECENT FINDINGS The current literature offers evidence supporting proposed mechanisms that induce TIC, such as platelet dysfunction, endogenous anticoagulation, endothelial activation, fibrinogen modifications, and hyperfibrinolysis. However, the majority of these data are mere associations; causative data are slowly unfolding through the utilization of animal models of hemorrhagic shock coupled with prospective observational clinical studies. SUMMARY As both clinical and basic science research expands our understanding of TIC, trauma patient care is improving substantially. Future studies should focus on the interplay between the coagulation pathways whose simultaneous or codependent dysregulation could offer the most advantageous points for intervention.
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Christ M, von Auenmueller KI, Liebeton J, Grett M, Dierschke W, Noelke JP, Breker IM, Trappe HJ. Using vascular closure devices following out-of-hospital cardiac arrest? Int J Med Sci 2015; 12:306-11. [PMID: 25897291 PMCID: PMC4402433 DOI: 10.7150/ijms.11343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 03/04/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES AND BACKGROUND Despite a generally broad use of vascular closure devices (VCDs), it remains unclear whether they can also be used in victims from out-of-hospital cardiac arrest (OHCA) treated with mild therapeutic hypothermia (MTH). METHODS All victims from OHCA who received immediate coronary angiography after OHCA between January 1(st) 2008 and December 31(st) 2013 were included in this study. The operator decided to either use a VCD (Angio-Seal™) or manual compression for femoral artery puncture. The decision to induce MTH was based on the clinical circumstances. RESULTS 76 patients were included in this study, 46 (60.5%) men and 30 (39.5%) women with a mean age of 64.2 ± 12.8 years. VCDs were used in 26 patients (34.2%), and 48 patients (63.2%) were treated with MTH. While there were significantly more overall vascular complications in the group of patients treated with MTH (12.5% versus 0.0%; p=0.05), vascular complications were similar between patients with VCD or manual compression, regardless of whether or not they were treated with MTH. CONCLUSION In our study, the overall rate of vascular complications related to coronary angiography was higher in patients treated with mild therapeutic hypothermia, but was not affected by the application of a vascular closure device. Therefore, our data suggest that the use of VCDs in victims from OHCA might be feasible and safe in patients treated with MTH as well, at least if the decision to use them is individually carefully determined.
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Affiliation(s)
- Martin Christ
- Department of Cardiology and Angiology, Marienhospital Herne, Ruhr - University Bochum, Germany
| | | | - Jeanette Liebeton
- Department of Cardiology and Angiology, Marienhospital Herne, Ruhr - University Bochum, Germany
| | - Martin Grett
- Department of Cardiology and Angiology, Marienhospital Herne, Ruhr - University Bochum, Germany
| | - Wolfgang Dierschke
- Department of Cardiology and Angiology, Marienhospital Herne, Ruhr - University Bochum, Germany
| | - Jan Peter Noelke
- Department of Cardiology and Angiology, Marienhospital Herne, Ruhr - University Bochum, Germany
| | - Irini Maria Breker
- Department of Cardiology and Angiology, Marienhospital Herne, Ruhr - University Bochum, Germany
| | - Hans-Joachim Trappe
- Department of Cardiology and Angiology, Marienhospital Herne, Ruhr - University Bochum, Germany
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Van Poucke S, Stevens K, Marcus AE, Lancé M. Hypothermia: effects on platelet function and hemostasis. Thromb J 2014; 12:31. [PMID: 25506269 PMCID: PMC4265340 DOI: 10.1186/s12959-014-0031-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/30/2014] [Indexed: 02/01/2023] Open
Abstract
Mild therapeutic hypothermia is considered standard care in the treatment of patients resuscitated from cardiac arrest. With increasingly more frequent concomitant use of platelet-inhibiting drugs, clinicians must be cognizant of the ramifications of hypothermia on platelet function as part of hemostasis. The effects of hypothermia on platelet function have been studied for more than 50 years, but the results are inconsistent and may be related to the circumstances during which hypothermia is achieved. This review summarizes current knowledge of platelet function during hypothermia and the impact on hemostasis.
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Affiliation(s)
- Sven Van Poucke
- />Department of Anesthesiology, Intensive Care Medicine, Emergency Care and Pain Therapy ZOL, Genk, Belgium
| | - Kris Stevens
- />Department of Anesthesiology, Maastricht University, Maastricht, Netherlands
| | | | - Marcus Lancé
- />Department of Anesthesiology, Maastricht University, Maastricht, Netherlands
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Bader MK. Clinical Q & A: Translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2014; 4:201-7. [PMID: 25423606 DOI: 10.1089/ther.2014.1516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kander T, Brokopp J, Erlinge D, Lood C, Schött U. Temperature effects on haemostasis in whole blood from ticagrelor- and aspirin-treated patients with acute coronary syndrome. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 75:27-35. [PMID: 25365333 DOI: 10.3109/00365513.2014.965735] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Comatose survivors after cardiac arrest are treated with mild induced hypothermia and potent platelet- inhibiting drugs after coronary stenting. Previous studies have shown an increased incidence of stent thrombosis during clopidogrel and aspirin treatment in conjunction with induced hypothermia. The aim of this study was to investigate the in vitro effect of induced hypo- and hyperthermia on blood from patients undergoing ticagrelor- and aspirin-mediated platelet inhibition. METHODS Whole blood from 15 patients with acute coronary syndrome who were treated with ticagrelor and aspirin and from eight healthy volunteers was incubated for 1 hour at 28, 33, 37, and 39°C. RESULTS In blood from patients with acute coronary syndrome, the activated clotting time (Sonoclot) was prolonged in mild hypothermic (33°C) compared to normothermic (37°C) samples. Sonoclot, clotting rate and platelet function were decreased in hypothermic compared to normothermic samples. Platelet-induced activation and aggregation (Multiplate) was unchanged in mild hypothermic compared to normothermic samples. In contrast, mild hypothermia supported increased platelet activation as measured with flow cytometry with up-regulation of PAC-1 and P-selectin on the platelet surface. CONCLUSION In acute coronary syndrome patients treated with ticagrelor and aspirin, in vitro hypothermia to 33°C markedly increased platelet activity measured with flow cytometry, whereas viscoelastic coagulation test (Sonoclot) revealed a hypocoagulative response. Prospective clinical trials studying platelet inhibition at different temperatures and correlating changes in platelet function to bleeding or stent occlusion are needed.
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Affiliation(s)
- Thomas Kander
- Department of Intensive and Perioperative Care, Skåne University Hospital , Lund , Sweden
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Kander T, Dankiewicz J, Friberg H, Schött U. Platelet aggregation and clot formation in comatose survivors of cardiac arrest treated with induced hypothermia and dual platelet inhibition with aspirin and ticagrelor; a prospective observational study. Crit Care 2014; 18:495. [PMID: 25292183 PMCID: PMC4194371 DOI: 10.1186/s13054-014-0495-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 08/05/2014] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION We conducted a prospective observational study in cardiac arrest survivors treated with mild induced hypothermia, evaluating different platelet function tests at hypo- and normothermia. We also investigated the relation between gastric emptying and vasodilator stimulated phosphoprotein (VASP). METHODS Comatose survivors of out of hospital cardiac arrest were included and divided into two groups, depending on whether dual platelet inhibition with peroral ticagrelor and aspirin was given or not. The first blood samples (T1) were collected 12-24 hours after reaching target temperature (33°C) and were compared to blood samples collected 12-28 hours after reaching normothermia (37°C) (T2) within each group. All samples were analysed by Sonoclot viscoelasticity, flow cytometry based VASP and with multiple electrode aggregometry, Multiplate®; adenosine diphosphate (ADP), collagen (COL), thrombin receptor agonist peptide (TRAP) and arachidonic acid (ASPI). Sonoclot and Multiplate® instruments were set on in vivo temperatures. Gastric secretion from the nasogastric tube was measured to assess absorption of per orally administered antiplatelet drugs. Differences between T1 and T2 within each group were calculated using Wilcoxon matched pairs signed test. Significance levels were set at P <0.01. RESULTS In total, 23 patients were included. In patients with dual platelet inhibition (n =14) Multiplate®-analyses showed no changes in ADP stimulated platelets. COL, TRAP and ASPI aggregations were higher at T2 compared to T1. Sonoclot-analyses showed that activated clotting time (ACT) was unchanged but both clot rate (CR) and platelet function (PF) were higher at T2 compared to T1. VASP decreased from 53 ± 28(T1) to 24 ± 22(T2), (P <0.001). The average volume of gastric secretion aspirated before T1 correlated well with VASP (T1), r =0.81 (P <0.001). In patients with no platelet inhibition, (n =9) similar changes between T1 and T2 were seen as in patients with dual platelet inhibition while VASP was unchanged. CONCLUSIONS We have demonstrated increased platelet aggregation and strengthened clot formation over time in out of hospital cardiac arrest patients treated with hypothermia. In patients on oral dual platelet inhibition, the effect of ticagrelor was delayed, probably due to slow gastric emptying.
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Affiliation(s)
- Thomas Kander
- Department of Intensive and Perioperative Care, Skåne University Hospital and Lund University, Lund, Sweden
| | - Josef Dankiewicz
- Department of Intensive and Perioperative Care, Skåne University Hospital and Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Intensive and Perioperative Care, Skåne University Hospital and Lund University, Lund, Sweden
| | - Ulf Schött
- Department of Intensive and Perioperative Care, Skåne University Hospital and Lund University, Lund, Sweden
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Induced hypothermia reduces the hepatic inflammatory response in a swine multiple trauma model. J Trauma Acute Care Surg 2014; 76:1425-32. [PMID: 24854311 DOI: 10.1097/ta.0000000000000224] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mild therapeutic hypothermia following trauma has been introduced in several studies to reduce the posttraumatic inflammation and organ injury. In this study, we analyzed the effects of induced mild hypothermia (34°C) on the inflammation of the shock organs liver and kidney. METHODS In a porcine model of multiple trauma including blunt chest trauma, liver laceration, and hemorrhagic shock followed by fluid resuscitation, the influence of induced hypothermia on hepatic and renal damage and organ-specific inflammation were evaluated. A total of 40 pigs were randomly assigned to four groups, which were sham (anesthesia only) or trauma groups receiving either hypothermia or normothermia. The parameters analyzed were laboratory parameters (aspartate transaminase [AST], lactate dehydrogenase, urea, creatinine) as well as hepatic and renal cytokine expression determined by real-time polymerase chain reaction (interleukin 6 [IL-6], IL-8). Blinded analysis of histologic changes in the liver and kidney was performed. RESULTS Fifteen and a half hours following combined trauma, hepatic cytokine expression and liver damage were significantly increased in animals with normothermia compared with the respective sham group. Hypothermia, however, resulted in a fivefold reduced hepatic expression of IL-8 (mean ± SE, 2.4 ± 1.3; p = 0.01) when compared with the normothermic trauma group (IL-8, 12.8 ± 4.7). Accordingly, granulocyte infiltration and a histologic, semiquantitative score for liver injury were significantly higher in the normothermic trauma group. Serum AST levels raised significantly after trauma and normothermia compared with the respective sham group, while AST levels showed no difference from the sham groups in the hypothermic trauma group. In contrast, neither trauma nor hypothermia influenced the expression of IL-6 and IL-8 and tissue injury in the kidney. CONCLUSION Therapeutic hypothermia seems to attenuate the hepatic inflammatory response and the associated liver injury after severe trauma. Therefore, induced hypothermia might represent a potential therapeutic strategy to avoid posttraumatic organ dysfunction.
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Hildebrand F, Radermacher P, Ruchholtz S, Huber-Lang M, Seekamp A, Flohé S, van Griensven M, Andruszkow H, Pape HC. Relevance of induced and accidental hypothermia after trauma-haemorrhage-what do we know from experimental models in pigs? Intensive Care Med Exp 2014; 2:16. [PMID: 26266916 PMCID: PMC4512998 DOI: 10.1186/2197-425x-2-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 04/06/2014] [Indexed: 12/17/2022] Open
Abstract
Recent experimental research has either focused on the role of accidental hypothermia as part of the lethal triad after trauma or tried to elucidate the effects of therapeutically induced hypothermia on the posttraumatic course. Induced hypothermia seems to reduce the mortality in experimental models of trauma-haemorrhage. As potential mechanisms, a decrease of cellular metabolism, beneficial effects on haemodynamic function and an attenuation of the inflammatory response have been described. However, negative side effects of hypothermia have to be considered, such as impairment of the coagulatory function and immunosuppressive effects. Furthermore, the optimal strategy for the induction of hypothermia (magnitude, duration, timing, cooling rate, etc.) and subsequent rewarming remains unclear. Nevertheless, this piece of information is essential before considering hypothermia as a treatment strategy for severely injured patients. This review aims to elaborate the differences between accidental and induced hypothermia and to summarize the current knowledge of the potential therapeutic use of induced hypothermia suggested in porcine models of trauma-haemorrhage.
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Affiliation(s)
- Frank Hildebrand
- Department of Orthopedic Trauma and Reconstructive Surgery and Harald Tscherne Laboratory, University of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany,
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Hatch Q, Debarros M, Eckert M, Satterly S, Nelson D, Porta R, Lesperance R, Long W, Martin M. Acute coagulopathy in a porcine venous hemorrhage and ischemia reperfusion model. Am J Surg 2014; 207:637-41; discussion 641. [PMID: 24791624 DOI: 10.1016/j.amjsurg.2013.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/17/2013] [Accepted: 12/17/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injury-related coagulopathy is a complex process. We analyzed coagulation in a swine model of shock using rotational thromboelastometry (ROTEM). METHODS Forty-eight swine underwent laparotomy, 35% hemorrhage, supraceliac aortic cross-clamp, then reperfusion and resuscitation. ROTEM measurements and standard labs were taken at baseline and 6 hours into resuscitation. RESULTS Clot formation time (98 vs 53 seconds, P = .001) and international normalized ratio (1.67 vs 1.01, P < .001) were prolonged after resuscitation. Maximum clot firmness (61 vs 72 mm, P < .001) and fibrinogen levels (94 vs 165, P < .001) declined significantly during resuscitation. Despite decreased fibrinogen levels, there was no significant increase in fibrinolysis as measured by maximum lysis (3.9% vs 3.8%, P = .99). CONCLUSIONS ROTEM demonstrated the development of an acute coagulopathy. The most significant impacts on coagulopathy were seen with clot initiation and fibrin polymerization. Clot strength decreased over time, although there was little impact on clot breakdown because of fibrinolysis.
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Affiliation(s)
- Quinton Hatch
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Mia Debarros
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Matthew Eckert
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Steven Satterly
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Daniel Nelson
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Rees Porta
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Richard Lesperance
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - William Long
- Department of Surgery, Legacy Emanuel Medical Center, 2801 N Gantenbein Avenue, Portland, OR 97227, USA
| | - Matthew Martin
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA; Department of Surgery, Legacy Emanuel Medical Center, 2801 N Gantenbein Avenue, Portland, OR 97227, USA.
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Delfin G, Leary M, Perman SM, O'Rourke DM, Levine JM, Abella BS. Postarrest Targeted Temperature Management Immediately Following Craniotomy—A Case Report. Ther Hypothermia Temp Manag 2013; 3:143-6. [DOI: 10.1089/ther.2013.0012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gail Delfin
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marion Leary
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah M. Perman
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donald M. O'Rourke
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M. Levine
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin S. Abella
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, Pennsylvania
- Section of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
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