1
|
LaCroix IS, Moore EE, Cralley A, Cendali FI, Dzieciatkowska M, Hom P, Mitra S, Cohen M, Silliman C, Hansen KC, D'Alessandro A. Multiomics Signatures of Coagulopathy in a Polytrauma Swine Model Contrasted with Severe Multisystem Injured Patients. J Proteome Res 2024; 23:1163-1173. [PMID: 38386921 DOI: 10.1021/acs.jproteome.3c00581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Trauma-induced coagulopathy (TIC) is a leading contributor to preventable mortality in severely injured patients. Understanding the molecular drivers of TIC is an essential step in identifying novel therapeutics to reduce morbidity and mortality. This study investigated multiomics and viscoelastic responses to polytrauma using our novel swine model and compared these findings with severely injured patients. Molecular signatures of TIC were significantly associated with perturbed coagulation and inflammation systems as well as extensive hemolysis. These results were consistent with patterns observed in trauma patients who had multisystem injuries. Here, intervention using resuscitative endovascular balloon occlusion of the aorta following polytrauma in our swine model revealed distinct multiomics alterations as a function of placement location. Aortic balloon placement in zone-1 worsened ischemic damage and mitochondrial dysfunction, patterns that continued throughout the monitored time course. While placement in zone-III showed a beneficial effect on TIC, it showed an improvement in effective coagulation. Taken together, this study highlights the translational relevance of our polytrauma swine model for investigating therapeutic interventions to correct TIC in patients.
Collapse
Affiliation(s)
- Ian S LaCroix
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, United States
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado 80204, United States
| | - Alexis Cralley
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Francesca I Cendali
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Patrick Hom
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Sanchayita Mitra
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Mitchell Cohen
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Christopher Silliman
- Vitalant Research Institute, Denver, Colorado 80230, United States
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado 80045, United States
| |
Collapse
|
2
|
Thielen O, Mitra S, Debot M, Schaid T, Hallas W, Gallagher LT, Erickson C, Cralley A, Stafford P, Silliman C, D'Alessandro A, Hansen K, Sauaia A, Moore E, Mosnier L, Griffin J, Cohen M. Mitigation of trauma-induced endotheliopathy by activated protein C: A potential therapeutic for postinjury thromboinflammation. J Trauma Acute Care Surg 2024; 96:116-122. [PMID: 37733304 PMCID: PMC10841096 DOI: 10.1097/ta.0000000000004142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND Activated Protein C (aPC) plays dual roles after injury, driving both trauma-induced coagulopathy (TIC) by cleaving, and thus inactivating, factors Va and VIIIa and depressing fibrinolysis while also mediating an inflammomodulatory milieu via protease activated receptor-1 (PAR-1) cytoprotective signaling. Because of this dual role, it represents and ideal target for study and therapeutics after trauma. A known aPC variant, 3K3A-aPC, has been engineered to preserve cytoprotective activity while retaining minimal anticoagulant activity rendering it potentially ideal as a cytoprotective therapeutic after trauma. We hypothesized that 3K3A-aPC would mitigate the endotheliopathy of trauma by protecting against endothelial permeability. METHODS We used electric cell-substrate impedance sensing to measure permeability changes in real time in primary endothelial cells. These were cultured, grown to confluence, and treated with a 2 μg/mL solution of 3K3A-aPC at 180 minutes, 120 minutes, 60 minutes, 30 minutes prior to stimulation with ex vivo plasma taken from severely injured trauma patients (Injury Severity Score > 15 and BD < -6) (trauma plasma [TP]). Cells treated with thrombin and untreated cells were included in this study as control groups. Permeability changes were recorded in real time via electric cell-substrate impedance sensing for 30 minutes after treatment with TP. We quantified permeability changes in the control and treatment groups as area under the curve (AUC). Rac1/RhoA activity was also compared between these groups. Statistical significance was determined by one-way ANOVA followed by a post hoc analysis using Tukey's multiple comparison's test. RESULTS Treatment with aPC mitigated endothelial permeability induced by ex vivo trauma plasma at all pre-treatment time points. The AUC of the 30-minute 3K3A-aPC pretreatment group was higher than TP alone (mean diff. 22.12 95% CI [13.75, 30.49], p < 0.0001) (Figure). Moreover, the AUC of the 60-minute, 120-minute, and 180-minute pretreatment groups was also higher than TP alone (mean diff., 16.30; 95% confidence interval [CI], 7.93-24.67; 19.43; 95% CI, 11.06-27.80, and 18.65; 95% CI, 10.28-27.02;, all p < 0.0001, respectively). Rac1/RhoA activity was higher in the aPC pretreatment group when compared with all other groups ( p < 0.01). CONCLUSION Pretreatment with 3K3A-aPC, which retains its cytoprotective function but has only ~5% of its anticoagulant function, abrogates the effects of trauma-induced endotheliopathy. This represents a potential therapeutic treatment for dysregulated thromboinflammation for injured patients by minimizing aPC's role in trauma-induced coagulopathy while concurrently amplifying its essential cytoprotective function. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
Collapse
Affiliation(s)
- Otto Thielen
- From the Department of Gastrointestinal, Trauma, and Endocrine Surgery (O.T., S.M., M.D., T.S., W.H., L.T.G., C.E., A.C., P.S., C.S., A.D'A., K.H., A.S., E.M., M.C.), University of Colorado, Denver, Colorado; Department of Surgery (A.S., E.M.), Denver Health Medical Center, Denver, Colorado; and Department of Molecular Medicine (L.M., J.G.), Scripps Research, La Jolla, California
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Schaid TR, Mitra S, Stafford P, DeBot M, Thielen O, Hallas W, Cralley A, Gallagher L, Jeffrey D, Hansen KC, D'Alessandro A, Silliman CC, Dabertrand F, Cohen MJ. Endothelial Cell Calcium Influx Mediates Trauma-induced Endothelial Permeability. Ann Surg 2023:00000658-990000000-00719. [PMID: 38073572 DOI: 10.1097/sla.0000000000006164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2024]
Abstract
OBJECTIVE We aimed to investigate if ex vivo plasma from injured patients causes endothelial calcium (Ca2+) influx as a mechanism of trauma-induced endothelial permeability. SUMMARY BACKGROUND DATA Endothelial permeability after trauma contributes to post-injury organ dysfunction. While the mechanisms remain unclear, emerging evidence suggests intracellular Ca2+ signaling may play a role. METHODS Ex vivo plasma from injured patients with "Low Injury/Low Shock" (injury severity score [ISS]<15, base excess [BE])≥-6mEq/L) and "High Injury/High Shock" (ISS≥15, BE<-6mEq/L) were used to treat endothelial cells. Experimental conditions included Ca2+ removal from the extracellular buffer, cyclopiazonic acid pre-treatment to deplete intracellular Ca2+ stores, and GSK2193874 pre-treatment to block the TRPV4 Ca2+ channel. Live cell fluorescence microscopy and ECIS were used to assess cytosolic Ca2+ increases and permeability, respectively. Western blot and live cell actin staining were used to assess myosin light chain (MLC) phosphorylation and actomyosin contraction. RESULTS Compared to Low Injury/Low Shock plasma, High Injury/High Shock induced greater cytosolic Ca2+ increase. Cytosolic Ca2+ increase, MLC phosphorylation, and actin cytoskeletal contraction were lower without extracellular Ca2+ present. High Injury/High Shock plasma did not induce endothelial permeability without extracellular Ca2+ present. TRPV4 inhibition lowered trauma plasma-induced endothelial Ca2+ influx and permeability. CONCLUSIONS This study illuminates a novel mechanism of post-injury endotheliopathy involving Ca2+ influx via the TRPV4 channel. TRPV4 inhibition mitigates trauma-induced endothelial permeability. Moreover, widespread endothelial Ca2+ influx may contribute to trauma-induced hypocalcemia. This study provides the mechanistic basis for the development of Ca2+-targeted therapies and interventions in the care of severely injured patients.
Collapse
Affiliation(s)
- Terry R Schaid
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - Sanchayita Mitra
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - Preston Stafford
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - Margot DeBot
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - Otto Thielen
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - William Hallas
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - Alexis Cralley
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - Lauren Gallagher
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| | - Danielle Jeffrey
- University of Colorado Denver, School of Medicine, Department of Anesthesiology, Aurora, CO
- University of Colorado Denver, School of Medicine, Department of Pharmacology, Aurora, CO
| | - Kirk C Hansen
- University of Colorado Denver, School of Medicine, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Angelo D'Alessandro
- University of Colorado Denver, School of Medicine, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Christopher C Silliman
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
- University of Colorado Denver, School of Medicine, Department of Pediatrics, Aurora, CO
- Vitalant Research Institute, Denver, CO
| | - Fabrice Dabertrand
- University of Colorado Denver, School of Medicine, Department of Anesthesiology, Aurora, CO
- University of Colorado Denver, School of Medicine, Department of Pharmacology, Aurora, CO
| | - Mitchell J Cohen
- University of Colorado Denver, School of Medicine, Department of Surgery, Trauma Research Center, Aurora, CO
| |
Collapse
|
4
|
Wham C, Morin T, Sauaia A, McIntyre R, Urban S, McVaney K, Cohen M, Cralley A, Moore EE, Campion EM. Prehospital ETCO 2 is predictive of death in intubated and non-intubated patients. Am J Surg 2023; 226:886-890. [PMID: 37563074 DOI: 10.1016/j.amjsurg.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/18/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. METHODS This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. RESULTS Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index = 22 mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p = 0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p = 0.03). CONCLUSION Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients.
Collapse
Affiliation(s)
- Courtney Wham
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Theresa Morin
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Angela Sauaia
- University of Colorado, School of Public Health (AS), United States.
| | - Robert McIntyre
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Shane Urban
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Kevin McVaney
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Mitchell Cohen
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Alexis Cralley
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Eric M Campion
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| |
Collapse
|
5
|
LaCroix IS, Cralley A, Moore EE, Cendali FI, Dzieciatkowska M, Hom P, Mitra S, Cohen M, Silliman C, Sauaia A, Hansen KC, D’Alessandro A. Omics Signatures of Tissue Injury and Hemorrhagic Shock in Swine. Ann Surg 2023; 278:e1299-e1312. [PMID: 37334680 PMCID: PMC10728352 DOI: 10.1097/sla.0000000000005944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Advanced mass spectrometry methods were leveraged to analyze both proteomics and metabolomics signatures in plasma upon controlled tissue injury (TI) and hemorrhagic shock (HS)-isolated or combined-in a swine model, followed by correlation to viscoelastic measurements of coagulopathy via thrombelastography. BACKGROUND TI and HS cause distinct molecular changes in plasma in both animal models and trauma patients. However, the contribution to coagulopathy of trauma, the leading cause of preventable mortality in this patient population remains unclear. The recent development of a swine model for isolated or combined TI+HS facilitated the current study. METHODS Male swine (n=17) were randomized to either isolated or combined TI and HS. Coagulation status was analyzed by thrombelastography during the monitored time course. The plasma fractions of the blood draws (at baseline; end of shock; and at 30 minutes, 1, 2, and 4 hours after shock) were analyzed by mass spectrometry-based proteomics and metabolomics workflows. RESULTS HS-isolated or combined with TI-caused the most severe omic alterations during the monitored time course. While isolated TI delayed the activation of coagulation cascades. Correlation to thrombelastography parameters of clot strength (maximum amplitude) and breakdown (LY30) revealed signatures of coagulopathy which were supported by analysis of gene ontology-enriched biological pathways. CONCLUSION The current study provides a comprehensive characterization of proteomic and metabolomic alterations to combined or isolated TI and HS in a swine model and identifies early and late omics correlates to viscoelastic measurements in this system.
Collapse
Affiliation(s)
- Ian S. LaCroix
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Alexis Cralley
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Francesca I Cendali
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Patrick Hom
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Sanchayita Mitra
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | | | - Christopher Silliman
- Vitalant Research Institute, Denver, CO, USA
- Department of Pediatrics, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Angela Sauaia
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
6
|
Witthauer L, Roussakis E, Cascales JP, Goss A, Li X, Cralley A, Yoeli D, Moore HB, Wang Z, Wang Y, Li B, Huang CA, Moore EE, Evans CL. Development and in-vivo validation of a portable phosphorescence lifetime-based fiber-optic oxygen sensor. Sci Rep 2023; 13:14782. [PMID: 37679415 PMCID: PMC10484954 DOI: 10.1038/s41598-023-41917-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023] Open
Abstract
Oxygenation is a crucial indicator of tissue viability and function. Oxygen tension ([Formula: see text]), i.e. the amount of molecular oxygen present in the tissue is a direct result of supply (perfusion) and consumption. Thus, measurement of [Formula: see text] is an effective method to monitor tissue viability. However, tissue oximetry sensors commonly used in clinical practice instead rely on measuring oxygen saturation ([Formula: see text]), largely due to the lack of reliable, affordable [Formula: see text] sensing solutions. To address this issue we present a proof-of-concept design and validation of a low-cost, lifetime-based oxygen sensing fiber. The sensor consists of readily-available off-the shelf components such as a microcontroller, a light-emitting diode (LED), an avalanche photodiode (APD), a temperature sensor, as well as a bright in-house developed porphyrin molecule. The device was calibrated using a benchtop setup and evaluated in three in vivo animal models. Our findings show that the new device design in combination with the bright porphyrin has the potential to be a useful and accurate tool for measuring [Formula: see text] in tissue, while also highlighting some of the limitations and challenges of oxygen measurements in this context.
Collapse
Affiliation(s)
- Lilian Witthauer
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Emmanuel Roussakis
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Juan Pedro Cascales
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Avery Goss
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Xiaolei Li
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Alexis Cralley
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Dor Yoeli
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Zhaohui Wang
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Yong Wang
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Bing Li
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Christene A Huang
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver/Anschutz Medical Campus, Aurora, CO, USA
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA.
| |
Collapse
|
7
|
DeBot M, Erickson C, Kelher M, Schaid TR, Moore EE, Sauaia A, Cralley A, LaCroix I, D’Alessandro A, Hansen K, Cohen MJ, Silliman CC, Coleman J. Platelet and cryoprecipitate transfusions from female donors improve coagulopathy in vitro. J Trauma Acute Care Surg 2023; 94:497-503. [PMID: 36728345 PMCID: PMC10038850 DOI: 10.1097/ta.0000000000003857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Females are relatively hypercoagulable compared with males, with increased platelet aggregation and improved clot dynamics. However, sex differences in coagulation have not yet been considered in transfusion guidelines. Therefore, our objective was to evaluate hemostatic differences in sex concordant and sex discordant cryoprecipitate and platelet transfusions. We hypothesized that transfusion of blood products from female donors results in improved coagulopathy compared with male blood products. METHODS This was a cohort study evaluating sex dimorphisms in coagulation assays and clotting factors in healthy volunteer plasma and cryoprecipitate. Sex dimorphisms in transfusions were evaluated using an in vitro coagulopathy model. Female or male platelets or single-donor cryoprecipitate was added to "recipient" whole blood after dilution of recipient blood with citrated saline to provoke a coagulopathic profile. Citrated native thromboelastography was then performed. Liquid chromatography/mass spectroscopy was performed on single-donor cryoprecipitate to evaluate sex dimorphisms in the proteome of cryoprecipitate. RESULTS Females have an increased proportion of functional fibrinogen. Transfusion of female-donor platelets and cryoprecipitate induces a larger decrease in R time and greater increase in angle than male-donor platelets or cryoprecipitate. Female-donor cryoprecipitate has increased factor V and factor XIII compared with male cryoprecipitate, and comprehensive proteomics revealed sex differences in several proteins with potential immunological significance. CONCLUSION Platelets and cryoprecipitate from female donors improve coagulopathy more than male blood products in vitro. Increased factor V and factor XIII activity as well as increased fibrinogen activity in female donors appears to drive this disparity. Sex differences in the proteome of cryoprecipitate may influence how transfusions modulate the thromboinflammation of trauma. The differing hemostatic profiles of female and male blood products suggest the potential role of sex-specific transfusions guidelines in hemostatic resuscitation.
Collapse
Affiliation(s)
- Margot DeBot
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Christopher Erickson
- University of Colorado, School of Medicine, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Marguerite Kelher
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
- Vitalant Research Institute, Vitalent Mountain Division, Denver, CO
| | - Terry R. Schaid
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Ernest E. Moore
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
- Denver Health Medical Center, Ernest E Moore Shock Trauma Center, Denver, CO
| | - Angela Sauaia
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
- University of Colorado, School of Public Health, Management and Policy, Department of Health Systems, Aurora, CO
| | - Alexis Cralley
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Ian LaCroix
- University of Colorado, School of Medicine, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Angelo D’Alessandro
- University of Colorado, School of Medicine, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Kirk Hansen
- University of Colorado, School of Medicine, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Mitchell J. Cohen
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Christopher C. Silliman
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
- Vitalant Research Institute, Vitalent Mountain Division, Denver, CO
| | - Julia Coleman
- University of Colorado, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| |
Collapse
|
8
|
Schaid TR, Cohen MJ, D'Alessandro A, Silliman CC, Moore EE, Sauaia A, Dzieciatkowska M, Hallas W, Thielen O, DeBot M, Cralley A, LaCroix I, Erickson C, Mitra S, Banerjee A, Jones K, Hansen KC. TRAUMA INDUCES INTRAVASCULAR HEMOLYSIS, EXACERBATED BY RED BLOOD CELL TRANSFUSION AND ASSOCIATED WITH DISRUPTED ARGININE-NITRIC OXIDE METABOLISM. Shock 2023; 59:12-19. [PMID: 36378232 PMCID: PMC9892361 DOI: 10.1097/shk.0000000000002036] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
ABSTRACT Background: Severe injury can provoke systemic processes that lead to organ dysfunction, and hemolysis of both native and transfused red blood cells (RBCs) may contribute. Hemolysis can release erythrocyte proteins, such as hemoglobin and arginase-1, the latter with the potential to disrupt arginine metabolism and limit physiologic NO production. We aimed to quantify hemolysis and arginine metabolism in trauma patients and measure association with injury severity, transfusions, and outcomes. Methods: Blood was collected from injured patients at a level I trauma center enrolled in the COMBAT (Control of Major Bleeding After Trauma) trial. Proteomics and metabolomics were performed on plasma fractions through liquid chromatography coupled with mass spectrometry. Abundances of erythrocyte proteins comprising a hemolytic profile as well as haptoglobin, l -arginine, ornithine, and l -citrulline (NO surrogate marker) were analyzed at different timepoints and correlated with transfusions and adverse outcomes. Results: More critically injured patients, nonsurvivors, and those with longer ventilator requirement had higher levels of hemolysis markers with reduced l -arginine and l -citrulline. In logistic regression, elevated hemolysis markers, reduced l -arginine, and reduced l -citrulline were significantly associated with these adverse outcomes. An increased number of blood transfusions were significantly associated with elevated hemolysis markers and reduced l -arginine and l -citrulline independently of New Injury Severity Score and arterial base excess. Conclusions: Severe injury induces intravascular hemolysis, which may mediate postinjury organ dysfunction. In addition to native RBCs, transfused RBCs can lyse and may exacerbate trauma-induced hemolysis. Arginase-1 released from RBCs may contribute to the depletion of l -arginine and the subsequent reduction in the NO necessary to maintain organ perfusion.
Collapse
Affiliation(s)
- Terry R Schaid
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Mitchell J Cohen
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | | | | | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - William Hallas
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Otto Thielen
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Margot DeBot
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Alexis Cralley
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Ian LaCroix
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Christopher Erickson
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Sanchayita Mitra
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Anirban Banerjee
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Kenneth Jones
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado Denver, Aurora, Colorado
| |
Collapse
|
9
|
Werner NL, Moore EE, Hoehn M, Lawless R, Coleman JR, Freedberg M, Heelan AA, Platnick KB, Cohen MJ, Coleman JJ, Campion EM, Fox CJ, Mauffrey C, Cralley A, Pieracci FM, Burlew CC. Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury 2022; 53:3365-3370. [PMID: 36038388 DOI: 10.1016/j.injury.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
Collapse
Affiliation(s)
- Nicole L Werner
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America.
| | - Ernest E Moore
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Melanie Hoehn
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Ryan Lawless
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Julia R Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mari Freedberg
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alicia A Heelan
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - K Barry Platnick
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mitchell J Cohen
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Jamie J Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Eric M Campion
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Charles J Fox
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Cyril Mauffrey
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alexis Cralley
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Fredric M Pieracci
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Clay Cothren Burlew
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| |
Collapse
|
10
|
Werner NL, Cralley A, Lawless R, Platnick KB, Cohen MJ, Coleman JJ, Hoehn M, Campion E, Pieracci FM, Burlew CC. Time to Look for Another Infectious Source? White Blood Cell Trends during Ventilator-Associated Pneumonia. Surg Infect (Larchmt) 2022; 23:656-660. [PMID: 35930247 DOI: 10.1089/sur.2022.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) continues to plague patients in intensive care units (ICUs) throughout the world. Persistent leukocytosis despite antibiotic treatment for VAP can have many etiologies including normal inflammatory response, inadequate VAP antimicrobial therapy, and the presence of additional infectious diagnoses. Hypothesis: Surgical patients with VAP and a second infectious source have a different white blood cell count (WBC) trend than patients with VAP alone. Patients and Methods: Retrospective, single-center study of surgical ICU patients diagnosed with VAP (>104 CFU/mL on semi-quantitative culture) between January 2019 and June 2020. Chart review identified additional infections diagnosed during VAP treatment. White blood cell count values were compared between patients treated for VAP alone (VAP-alone) and those with additional infections (VAP-plus) using a Wilcoxon test. Univariable analysis compared admission type, surgeries, and steroid use between cohorts. Results: Eighty-eight VAPs were included for analysis; 61 (69%) were VAP-alone and 27 (31%) VAP-plus. Average age was 47.1 ± 16.7 years, 78% were male, and 93% were trauma admissions. Median hospital day of VAP diagnosis was six (interquartile range [IQR], 4-10). Nearly all patients (99%) were started on initial antibiotic agents to which the VAP organism was sensitive. Daily WBC was higher for VAP-plus compared with VAP-alone on days five, six, and seven of treatment. The maximum WBC was higher for VAP-plus (21.6 k/mcL vs. 16.1 k/mcL; p = 0.02). There were no differences in admission types, number of surgeries, or steroid use between groups. Conclusions: Providers should have increased suspicion for additional sources of infection when ICU patients with a VAP continue to have elevated WBC despite appropriate antibiotic therapy.
Collapse
Affiliation(s)
| | - Alexis Cralley
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Ryan Lawless
- Denver Health Medical Center, Denver, Colorado, USA
| | | | - Mitchell J Cohen
- University of Colorado School of Medicine, Denver, Colorado, USA
| | | | - Melanie Hoehn
- UCHealth Medical Center of the Rockies, Loveland, Colorado, USA
| | - Eric Campion
- Denver Health Medical Center, Denver, Colorado, USA
| | | | | |
Collapse
|
11
|
Schaid T, Mitra S, DeBot M, Cralley A, Erickson C, Dabertrand F, Fontaine J, D'Alessandro A, Hansen K, Jones K, Sauaia A, Banerjee A, Silliman C, Moore E, Cohen M. Calcium Signaling in Trauma: Increased Intracellular Calcium Flux in the Severely Injured. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r1940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
12
|
Morton A, Cralley A, Brooke-Sanchez M, Pieracci FM. Laparoscopic common bile duct exploration by acute care surgeons saves time and money compared to ERCP. Am J Surg 2022; 224:116-119. [DOI: 10.1016/j.amjsurg.2022.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/03/2022] [Accepted: 03/22/2022] [Indexed: 12/01/2022]
|
13
|
Cralley A, Madsen H, Robinson C, Platnick C, Madison S, Trabert T, Cohen M, Cothren Burlew C, Sauaia A, Platnick KB. Sustainability of Palliative Care Principles in the Surgical Intensive Care Unit Using a Multi-Faceted Integration Model. J Palliat Care 2022; 37:562-569. [PMID: 35138198 DOI: 10.1177/08258597221079438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE(S) Understanding patient goals of care is essential in any setting, and especially so in an urban, safety net trauma centers' Surgical Intensive Care Units (SICU). This underscores the need for implementation of palliative care principles and practices, such as identification of surrogate decision makers, goals-of-care discussions, and CPR directives, in the SICU. METHODS A pragmatic, quality improvement study utilizing a retrospective, pre- and post-intervention continuum analysis. Interventions included a surgeon champion, resident education, and an electronic medical record template, called the Advanced Care Planning (ACP) Note, for use on daily rounds. We reviewed the charts of all adults admitted to the SICU before, during, and after these interventions to identify the incidence of surrogate decision maker documentation by SICU residents. RESULTS There was an early and enthusiastic adoption in ACP note utilization by SICU residents over the study period. Rates of documenting surrogate decision makers increased throughout the study period (p < 0.0001). Having an ACP note in the chart was associated with significantly higher rates of documented surrogate decision makers (p < 0.0001). CONCLUSIONS Through the integration of targeted education, standardization of an electronic medical record tool for palliative care documentation, and incorporation of palliative care goals into daily rounding ICU checklists, we significantly increased identification of surrogate decision makers in the SICU of our urban Level One trauma center. Chart review from one year post-intervention showed sustained commitment to the use of the ACP note and identification of surrogate decision makers.
Collapse
Affiliation(s)
| | - Helen Madsen
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | | | | | - Angela Sauaia
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | |
Collapse
|
14
|
Campion EM, Cralley A, Sauaia A, Buchheit RC, Brown AT, Spalding MC, LaRiccia A, Moore S, Tann K, Leskovan J, Camazine M, Barnes SL, Otaibi B, Hazelton JP, Jacobson LE, Williams J, Castillo R, Stewart NJ, Elterman JB, Zier L, Goodman M, Elson N, Miner J, Hardman C, Kapoen C, Mendoza AE, Schellenberg M, Benjamin E, Wakam GK, Alam HB, Kornblith LZ, Callcut RA, Coleman LE, Shatz DV, Burruss S, Linn AC, Perea L, Morgan M, Schroeppel TJ, Stillman Z, Carrick MM, Gomez MF, Berne JD, McIntyre RC, Urban S, Nahmias J, Tay E, Cohen M, Moore EE, McVaney K, Burlew CC. Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial. J Trauma Acute Care Surg 2022; 92:355-361. [PMID: 34686640 DOI: 10.1097/ta.0000000000003447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE Diagnostic test, level III.
Collapse
Affiliation(s)
- Eric M Campion
- From the Department of Surgery (E.M.C., A.C., M. Cohen, E.E.M., C.C.B.), Denver Health Medical Center, Denver, Colorado; School of Public Health (A.S.), University of Colorado, Aurora, Colorado; Department of Surgery (R.C.B., A.T.B.), Erlanger Health System, Chattanooga, Tennessee; Department of Surgery (M.C.S., A.L.), Grant Medical Center, Columbus, Ohio; Department of Surgery (S.M., K.T.), Wakemed, Raleigh, North Carolina; Department of Surgery (J.L.), Mercy Health, Toledo, Ohio; Department of Surgery (M. Camazine, S.L.B.), University of Missouri Health Care, Columbia, Missouri; Department of Surgery (B.O., J.P.H.), Penn State Health, Hershey, Pennsylvania; Department of Surgery (L.E.J., J.W.), Ascension, Indianapolis, Indiana; Department of Surgery (R.C., N.J.S.), St. Lukes University Health Network, Bethlehem, Pennsylvania; Department of Surgery (J.B.E., L.Z.), UCHealth Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (M.G., N.E.), University of Cincinnati, Cincinnati, Ohio; Department of Surgery (J.M., C.H.), Premier Health Miami Valley, Dayton, Ohio; Department of Surgery (C.K., A.E.M.), Massachusetts General Hospital, Boston, Massachusetts; USC Medical Center, University of Southern California (M.S., E.B.), Los Angeles, California; Department of Surgery (G.K.W., H.B.A.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (L.Z.K., R.A.C.), Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California; Department of Surgery (L.E.C., D.V.S.), University of California, Davis, Sacramento, California; Department of Surgery (S.B., A.C.L.), Loma Linda University Health, Loma Linda, California; Department of Surgery (L.P., M.M.), Penn Medicine, Philadelphia, Pennsylvania; Department of Surgery (T.J.S., Z.S.), UCHealth Memorial Hospital, Springs Colorado, Colorado; Department of Surgery (M.M.C.), Medical City Plano, Plano, Texas; Department of Surgery (M.F.G., J.D.B.), Broward Health, Ft. Lauderdale, Florida; Department of Surgery (R.C.M., S.U.), University of Colorado Anschutz, Aurora, Colorado; University of California, Irvine (J.N., E.T.), Irvine, CA; and Denver Paramedics, Department of Emergency Medicine (K.M.), Denver Health Medical Center, Denver, Colorado
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Leasia KN, Ciarallo C, Prins JTH, Preslaski C, Perkins-Pride E, Hardin K, Cralley A, Burlew CC, Coleman JJ, Cohen MJ, Lawless R, Platnick KB, Moore EE, Pieracci FM. A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures. J Trauma Acute Care Surg 2021; 91:872-878. [PMID: 33951024 DOI: 10.1097/ta.0000000000003264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Locoregional analgesia (LRA) remains underused in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF. METHODS Noninferiority, single-center, randomized clinical trial (2017-2020) was performed. Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space), and LB involved thoracoscopic intercostal blocks of ribs 3 to 8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function score, measured daily for 5 days postoperatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality. RESULTS Thirty-four patients were enrolled: 16 IC and 18 LB. Age, Injury Severity Score, RibScore, Blunt Pulmonary Contusion Score, and use of nonnarcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p = 0.23). There was no significant difference in Sequential Clinical Assessment of Respiratory Function score between the IC and LB groups. On postoperative days 2 to 4, narcotic requirements were less than half in the LB, as compared with the IC group; however, this difference was not statistically significant. Average wholesale price was US $605 for IC and US $434 for LB. CONCLUSION In this noninferiority trial, LB provided at least comparable and potentially superior LRA as compared with IC among patients undergoing SSRF. LEVEL OF EVIDENCE Therapeutic, level II.
Collapse
Affiliation(s)
- Kiara N Leasia
- From the Department of Surgery (K.N.L., J.T.H.P., E.P.-P., K.H., A.C., C.C.B., J.J.C., M.J.C., R.L., K.B.P., E.E.M., F.M.P.), Department of Anesthesiology (C.C.), and Department of Pharmacy (C.P.), Denver Health and Hospital Authority, Denver, Colorado
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Hadley JB, Coleman JR, Moore EE, Lawless R, Burlew CC, Platnick B, Pieracci FM, Hoehn MR, Coleman JJ, Campion EM, Cohen MJ, Cralley A, Eitel AP, Bartley M, Vigneshwar N, Sauaia A, Fox CJ. Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center. J Trauma Acute Care Surg 2021; 91:295-301. [PMID: 33783417 PMCID: PMC8375411 DOI: 10.1097/ta.0000000000003198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. LEVEL OF EVIDENCE Therapeutic, level V.
Collapse
Affiliation(s)
- Jamie B Hadley
- From Department of Surgery, University of Colorado School of Medicine (J.B.H., J.R.C., A.P.E., M.B., N.V., C.J.F.); and Department of Surgery, Denver Health Medical Center (E.E.M., R.L., C.C.B., B.P., F.M.P., M.R.H., J.J.C., E.M.C., M.J.C., A.S., A.C.), Denver, Colorado
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Lawless RA, Cralley A, Qian S, Vasileiou G, Yeh DD. Antibiotics after Simple (Acute) Appendicitis are not Associated with Better Clinical Outcomes: A Post-Hoc Analysis of an EAST Multi-Center Study. Surg Infect (Larchmt) 2020; 22:504-508. [PMID: 32897168 DOI: 10.1089/sur.2019.348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The post-operative management of simple (acute) appendicitis differs throughout the United States. Guidelines regarding post-operative antibiotic usage remain unclear, and treatment generally is dictated by surgeon preference. We hypothesize that post-operative antibiotic use for simple appendicitis is not associated with lower post-operative complication rates. Methods: In a post-hoc analysis in a large multi-center observational study, only patients with an intra-operative diagnosis of AAST EGS Grade I were included. Subjects were classified into those receiving post-operative antibiotics (POST) and those given pre-operative antibiotics only (NONE). Clinical outcomes examined were length of stay (LOS), 30-day emergency department (ED) visits and hospital re-admissions, secondary interventions, surgical site infection (SSI), and intra-abdominal abscess (IAA). Results: A total of 2,191 subjects were included, of whom 612 (28%) received post-operative antibiotics. Compared with the NONE group, POST patients were older (age 37 [range 26-50] versus 33 [26-46] years; p < 0.001), weighed more (82 [70-96] versus 79 [68-93] kg (p = 0.038), and had higher white blood cell counts (13.5 ± 4.2 versus 13.1 ± 4.4/103/mcL (p = 0.046), Alvarado Scores (6 [5-7] versus 6 [5-7]; p < 0.001), and Charlson Comorbidity Indices (median score 0 in both cohorts; p < 0.001). The POST patients had a longer LOS (1 [1-2] versus 1 [1-1] days; p < 0.001). There were no differences in the number who had ED visits within 30 days (9% versus 8%; p = 0.435), hospital re-admission (4% versus 2%; p = 0.165), an index hospitalization SSI (0.2% for both cohorts; p = 0.69), an SSI within 30 days (4% versus 2%; p = 0.165), index hospitalization IAA rate (0.3% versus 0.1%; p = 0.190), 30-day IAA (2% versus 1%; p = 0.71), index hospitalization interventions (0.5% versus 0.1%; p = 0.137) or 30-day secondary interventions (2% versus 1%; p = 0.155). Conclusions: Post-operative antibiotic use after appendectomy for simple appendicitis is not associated with better post-operative clinical outcomes at index hospitalization or at 30 days after discharge.
Collapse
Affiliation(s)
| | | | - Sinong Qian
- Mayo Clinic Scottsdale, Scottsdale, Arizona, USA
| | | | | | | |
Collapse
|
18
|
Brenner M, Moore L, Zakhary B, Schwed A, Cralley A, Romagnoli A, Fox C, Scalea T, Cothren Burlew C. Scalpel or Sheath? Outcomes Comparison Between Pre-Peritoneal Pelvic Packing and Angioembolization for Definitive Hemorrhage Control After REBOA. JEVTM 2020. [DOI: 10.26676/jevtm.v4i1.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ABSTRACT
Background: The role of angioembolization (AE) and pre-peritoneal pelvic packing (PPP) for pelvic hemorrhage control in the era of REBOA has not been well described. Our aim was to investigate outcomes of PPP and AE after REBOA.
Methods: Patients who received aortic occlusion (AO) at Zone 3 (distal abdominal aorta) plus PPP and/or AE at 3 high-volume REBOA centers between February 2013 and December 2018 were identified. Outcomes were compared between 3 groups based on procedures performed: REBOA with PPP only (RPPP), REBOA with angioembolization only (RAE), and REBOA with PPP and AE (RPPPAE).
Results: 58 patients underwent REBOA at Zone 3; 37 RPPP, 13 RAE, 8 RPPPAE. Mean age was 45±16 years, mean injury severity score (ISS) 35±13, mean SBP pre-AO was 71±19mmHg, and post-AO SBP was 110±34mmHg. In-hospital mortality was 28%, with the majority of deaths occurring in the intensive care unit (17%). Age, ISS, admission SBP, physiology on admission and at the time of AO, response to AO, admission hemoglobin, blood products transfused, and rate of local wound infections were not different between RPPP and RAE groups. Comparing RPPP to RAE groups, duration of AO was significantly lower in the RPPP group (45+34 vs 81+37 mins, p=0.012), while rates of AKI (14% vs 46%) and distal embolism (8% vs 31%) were higher in the RAE group (p=0.015, 0.04 respectively).There was no statistical difference in mortality between RPPP (22%) and RAE patients (39%), including on regression analysis controlling for duration of AO and ongoing CPR at the time of AO.
Conclusion: Despite a longer duration of AO and higher rates of ongoing CPR at the time of AO in RAE patients, mortality rates are similar whether hemostasis is achieved after REBOA with pelvic packing or angioembolization. RPPP results in significantly lower systemic and local complication rates.
Collapse
|
19
|
Cralley A, Jackson R, Pieracci F. Eliminating Routine Intra-operative Foley Catheters May Reduce Post-Operative Urinary Tract Infections in Bariatric Surgery Patients. Surg Obes Relat Dis 2018. [DOI: 10.1016/j.soard.2018.09.306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|