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Schofield H, Rossetto A, Armstrong PC, Allan HE, Warner TD, Brohi K, Vulliamy P. Immature platelet dynamics are associated with clinical outcomes after major trauma. J Thromb Haemost 2024; 22:926-935. [PMID: 38101576 DOI: 10.1016/j.jtha.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/24/2023] [Accepted: 12/02/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Major trauma results in dramatic changes in platelet behavior. Newly formed platelets are more reactive than older platelets, but their contributions to hemostasis and thrombosis after severe injury have not been previously evaluated. OBJECTIVES To determine how immature platelet metrics and plasma thrombopoietin relate to clinical outcomes after major injury. METHODS A prospective observational cohort study was performed in adult trauma patients. Platelet counts and the immature platelet fraction (IPF) were measured at admission and 24 hours, 72 hours, and 7 days after injury. Thromboelastometry was performed at admission. Plasma thrombopoietin, c-Mpl, and GPIbα were quantified in a separate cohort. The primary outcome was in-hospital mortality; secondary outcomes were venous thromboembolic events and multiple organ dysfunction syndrome (MODS). RESULTS On admission, immature platelet counts (IPCs) were significantly lower in nonsurvivors (n = 40) than in survivors (n = 236; 7.3 × 109/L vs 10.6 × 109/L; P = .009), but IPF did not differ. Similarly, impaired platelet function on thromboelastometry was associated with lower admission IPC (9.1 × 109/L vs 11.9 × 109/L; P < .001). However, at later time points, we observed significantly higher IPF and IPC in patients who developed venous thromboembolism (21.0 × 109/L vs 11.1 × 109/L; P = .02) and prolonged MODS (20.9 × 109/L vs 11 × 109/L; P = .003) than in those who did not develop complications. Plasma thrombopoietin levels at admission were significantly lower in nonsurvivors (P < .001), in patients with MODS (P < .001), and in those who developed venous thromboembolism (P = .04). CONCLUSION Lower levels of immature platelets in the acute phase after major injury are associated with increased mortality, whereas higher immature platelet levels at later time points may predispose to thrombosis and MODS.
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Affiliation(s)
- Henry Schofield
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Andrea Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Paul C Armstrong
- Centre for Immunobiology, Blizard Institute, Queen Mary University of London, London, UK
| | - Harriet E Allan
- Centre for Immunobiology, Blizard Institute, Queen Mary University of London, London, UK
| | - Timothy D Warner
- Centre for Immunobiology, Blizard Institute, Queen Mary University of London, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK.
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Saviano A, Perotti C, Zanza C, Longhitano Y, Ojetti V, Franceschi F, Bellou A, Piccioni A, Jannelli E, Ceresa IF, Savioli G. Blood Transfusion for Major Trauma in Emergency Department. Diagnostics (Basel) 2024; 14:708. [PMID: 38611621 PMCID: PMC11011783 DOI: 10.3390/diagnostics14070708] [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: 02/08/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Severe bleeding is the leading cause of death in patients with major trauma admitted to the emergency department. It is estimated that about 50% of deaths happen within a few minutes of the traumatic event due to massive hemorrhage; 30% of deaths are related to neurological dysfunction and typically happen within two days of trauma; and approximately 20% of patients died of multiorgan failure and sepsis within days to weeks of the traumatic event. Over the past ten years, there has been an increased understanding of the underlying mechanisms and pathophysiology associated with traumatic bleeding leading to improved management measures. Traumatic events cause significant tissue damage, with the potential for severe blood loss and the release of cytokines and hormones. They are responsible for systemic inflammation, activation of fibrinolysis pathways, and consumption of coagulation factors. As the final results of this (more complex in real life) cascade, patients can develop tissue hypoxia, acidosis, hypothermia, and severe coagulopathy, resulting in a rapid deterioration of general conditions with a high risk of mortality. Prompt and appropriate management of massive bleeding and coagulopathy in patients with trauma remains a significant challenge for emergency physicians in their daily clinical practice. Our review aims to explore literature studies providing evidence on the treatment of hemorrhage with blood support in patients with trauma admitted to the Emergency Department with a high risk of death. Advances in blood transfusion protocols, along with improvements in other resuscitation strategies, have become one of the most important issues to face and a key topic of recent clinical research in this field.
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Affiliation(s)
- Angela Saviano
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (A.S.); (F.F.)
| | - Cesare Perotti
- Division of Immunohaematology and Transfusion, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Christian Zanza
- Geriatric Medicine Residency Program, University of Rome “Tor Vergata”, 00133 Rome, Italy;
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA;
- Department of Emergency Medicine-Emergency Medicine Residency Program, Humanitas University-Research Hospital, 20089 Rozzano, Italy
| | | | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (A.S.); (F.F.)
- Università Cattolica, 00168 Roma, Italy; (V.O.); (A.P.)
| | - Abdelouahab Bellou
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA;
- Institute of Sciences in Emergency Medicine, Department of Emergency Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | | | - Eugenio Jannelli
- Department of Orthopedics and Traumatology, Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | | | - Gabriele Savioli
- Department of Emergency Medicine, Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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3
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Kocoglu Barlas U. Response to Beyan on the letter to the editor "Mean platelet volume values may not be a marker of mortality in patients with severe trauma". Wien Klin Wochenschr 2023; 135:649-650. [PMID: 37855933 DOI: 10.1007/s00508-023-02294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Ulkem Kocoglu Barlas
- Faculty of Medicine, Goztepe Prof Dr Suleyman Yalcin City Hospital, Istanbul Medeniyet University, Egitim distinct, Fahrettin Kerim Gokay street, Kadikoy/Istanbul, Turkey.
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4
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Sloos PH, Maas MAW, Meijers JCM, Nieuwland R, Roelofs JJTH, Juffermans NP, Kleinveld DJB. Anti-high-mobility group box-1 treatment strategies improve trauma-induced coagulopathy in a mouse model of trauma and shock. Br J Anaesth 2023; 130:687-697. [PMID: 36967283 DOI: 10.1016/j.bja.2023.01.026] [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: 08/19/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Trauma-induced coagulopathy is associated with platelet dysfunction and contributes to early mortality after traumatic injury. Plasma concentrations of the damage molecule high-mobility group box-1 (HMGB-1) increase after trauma, which may contribute to platelet dysfunction. We hypothesised that inhibition of HMGB-1 with a monoclonal antibody (mAb) or with recombinant thrombomodulin (rTM) improves trauma-induced coagulopathy in a murine model of trauma and shock. METHODS Male 129S2/SvPasOrlRJ mice were anaesthetised, mechanically ventilated, and randomised into five groups: (i) ventilation control (VENT), (ii) trauma/shock (TS), (iii) TS+anti-HMGB-1 mAb (TS+AB), (iv) TS+rTM (TS+TM), and (v) TS+anti-HMGB-1 mAb+rTM (TS+COMBI). Primary outcome was rotational thromboelastometry EXTEM. Secondary outcomes included tail bleeding time, platelet count, plasma HMGB-1 concentration, and platelet activation. RESULTS Trauma and shock resulted in a hypocoagulable thromboelastometry profile, increased plasma HMGB-1, and increased platelet activation markers. TS+AB was associated with improved clot firmness after 5 min compared with TS (34 [33-37] vs 32 [29-34] mm; P=0.043). TS+COMBI was associated with decreased clot formation time (98 [92-125] vs 122 [111-148] s; P=0.018) and increased alpha angle (77 [72-78] vs 69 [64-71] degrees; P=0.003) compared with TS. TS+COMBI also reduced tail bleeding time compared with TS (P=0.007). The TS+TM and TS+COMBI groups had higher platelet counts compared with TS (P=0.044 and P=0.041, respectively). CONCLUSIONS Inhibition of HMGB-1 early after trauma in a mouse model improves clot formation and strength, preserves platelet count, and decreases bleeding time.
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Affiliation(s)
- Pieter H Sloos
- Amsterdam UMC Location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands
| | - M Adrie W Maas
- Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands
| | - Joost C M Meijers
- Amsterdam UMC Location University of Amsterdam, Department of Experimental Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Sanquin Research, Department of Molecular Hematology, Amsterdam, the Netherlands
| | - Rienk Nieuwland
- Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Clinical Chemistry, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Vesicle Observation Center, Amsterdam, the Netherlands
| | - Joris J T H Roelofs
- Amsterdam UMC Location University of Amsterdam, Department of Pathology, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Amsterdam UMC Location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands; Onze Lieve Vrouwe Gasthuis, Department of Intensive Care Medicine, Amsterdam, the Netherlands
| | - Derek J B Kleinveld
- Amsterdam UMC Location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands; Erasmus MC, Department of Anesthesiology, Rotterdam, the Netherlands.
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5
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Zanza C, Romenskaya T, Racca F, Rocca E, Piccolella F, Piccioni A, Saviano A, Formenti-Ujlaki G, Savioli G, Franceschi F, Longhitano Y. Severe Trauma-Induced Coagulopathy: Molecular Mechanisms Underlying Critical Illness. Int J Mol Sci 2023; 24:ijms24087118. [PMID: 37108280 PMCID: PMC10138568 DOI: 10.3390/ijms24087118] [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: 02/24/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/29/2023] Open
Abstract
Trauma remains one of the leading causes of death in adults despite the implementation of preventive measures and innovations in trauma systems. The etiology of coagulopathy in trauma patients is multifactorial and related to the kind of injury and nature of resuscitation. Trauma-induced coagulopathy (TIC) is a biochemical response involving dysregulated coagulation, altered fibrinolysis, systemic endothelial dysfunction, platelet dysfunction, and inflammatory responses due to trauma. The aim of this review is to report the pathophysiology, early diagnosis and treatment of TIC. A literature search was performed using different databases to identify relevant studies in indexed scientific journals. We reviewed the main pathophysiological mechanisms involved in the early development of TIC. Diagnostic methods have also been reported which allow early targeted therapy with pharmaceutical hemostatic agents such as TEG-based goal-directed resuscitation and fibrinolysis management. TIC is a result of a complex interaction between different pathophysiological processes. New evidence in the field of trauma immunology can, in part, help explain the intricacy of the processes that occur after trauma. However, although our knowledge of TIC has grown, improving outcomes for trauma patients, many questions still need to be answered by ongoing studies.
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Affiliation(s)
- Christian Zanza
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Tatsiana Romenskaya
- Department of Physiology and Pharmacology, Sapienza University of Rome, P. le A. Moro 5, 00185 Rome, Italy
| | - Fabrizio Racca
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Eduardo Rocca
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Fabio Piccolella
- Department of Anesthesia and Critical Care, AON SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Andrea Piccioni
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Angela Saviano
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - George Formenti-Ujlaki
- Department of Surgery, San Carlo Hospital, ASST Santi Paolo and Carlo, 20142 Milan, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
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