Shock index as predictor of massive transfusion and mortality in patients with trauma: a systematic review and meta-analysis

BACKGROUND

Management of bleeding trauma patients is still a difficult challenge. Massive transfusion (MT) requires resources to ensure the safety and timely delivery of blood products. Early prediction of MT need may be useful to shorten the time process of blood product preparation. The primary aim of this study was to assess the accuracy of shock index to predict the need for MT in adult patients with trauma. For the same population, we also assessed the accuracy of SI to predict mortality.

METHODS

This systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. We performed a systematic search on MEDLINE, Scopus, and Web of Science from inception to March 2022. Studies were included if they reported MT or mortality with SI recorded at arrival in the field or the emergency department. The risk of bias was assessed using the QUADAS-2.

RESULTS

Thirty-five studies were included in the systematic review and meta-analysis, for a total of 670,728 patients. For MT the overall sensibility was 0.68 [0.57; 0.76], the overall specificity was 0.84 [0.79; 0.88] and the AUC was 0.85 [0.81; 0.88]. Positive and Negative Likelihood Ratio (LR+; LR-) were 4.24 [3.18-5.65] and 0.39 [0.29-0.52], respectively. For mortality the overall sensibility was 0.358 [0.238; 0.498] the overall specificity 0.742 [0.656; 0.813] and the AUC 0.553 (confidence region for sensitivity given specificity: [0.4014; 0.6759]; confidence region for specificity given sensitivity: [0.4799; 0.6332]). LR+ and LR- were 1.39 [1.36-1.42] and 0.87 [0.85-0.89], respectively.

CONCLUSIONS

Our study demonstrated that SI may have a limited role as the sole tool to predict the need for MT in adult trauma patients. SI is not accurate to predict mortality but may have a role to identify patients with a low risk of mortality.

Pharmacogenetics in critical care: association between CYP3A5 rs776746 A/G genotype and acetaminophen response in sepsis and septic shock

BACKGROUND

Pharmacogenetics could represent a further resource to understand the interindividual heterogeneity of response of the host to sepsis and to provide a personalized approach to the critical care patient.

METHODS

Secondary analysis of data from the prospective observational study NCT02750163, in 50 adult septic and septic shock patients treated with Acetaminophen (ACT) for pyrexia. We investigated the presence of two polymorphisms, located respectively in the genes UGT1A1 and CYP3A5, that encode for proteins related to the hepatic metabolism of ACT. The main dependent variables explored were plasmatic concentration of ACT, body temperature and hepatic parameters.

RESULTS

8% of the patients carried CYP3A5 rs776746 A/G genotypes and showed significantly higher plasma levels of ACT than GG wild type patients, and than patients with UGT1A1 rs8330 C/G genotypes.

CONCLUSIONS

Identifying specific genotypes of response to ACT may be helpful to guide a more personalized titration of therapy in sepsis and septic shock. CYP3A5 might be a good biomarker for ACT metabolism; however further studies are needed to confirm this result.

TRIAL REGISTRATION

NCT02750163.

In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.

METHODS

EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.

FINDINGS

Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.

INTERPRETATION

Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required.

FUNDING

None.

Sublingual microcirculation in patients with SARS-CoV-2 undergoing veno-venous extracorporeal membrane oxygenation

Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a rescue treatment for severe acute respiratory failure refractory to conventional ventilation. We examined the alterations of sublingual microcirculation in patients with SARS-CoV-2 during VV-ECMO treatment and assessed the relationship between microvascular parameters and ventilation, hemodynamics, and laboratory tests.

Nine patients were included in the study and the following microcirculatory parameters were estimated: TVD 16.81 (14.46–18.6) mm/mm²; PVD 15.3 (14.09–17.96) mm/mm²; PPV 94.85% (93.82%–97.79%); MFI 2.5 (2.5–2.92); HI 0.4 (0.18–0.4). TVD and PVD were inversely related to D-dimer levels (rho = −0.667, p = 0.05 and rho = −0.733, p = 0.025 respectively), aspartate aminotransferase (AST) (rho = −0.886, p = 0.019 and rho = −0.886, p = 0.019 respectively) and alanine aminotransferase (ALT) (rho = −0.829, p = 0.042 and rho = −0.829, p = 0.042 respectively).

Our results showed an altered sublingual microcirculation in patients receiving VV-ECMO for severe SARS-CoV-2 and suggest a potential contribution of endothelia dysfunction to determine microvascular alteration.

Chemical modification of proteins by insertion of synthetic peptides using tandem protein trans-splicing

Manipulation of proteins by chemical modification is a powerful way to decipher their function. However, most ribosome-dependent and semi-synthetic methods have limitations in the number and type of modifications that can be introduced, especially in live cells. Here, we present an approach to incorporate single or multiple post-translational modifications or non-canonical amino acids into proteins expressed in eukaryotic cells. We insert synthetic peptides into GFP, NaV1.5 and P2X2 receptors via tandem protein trans-splicing using two orthogonal split intein pairs and validate our approach by investigating protein function. We anticipate the approach will overcome some drawbacks of existing protein enigineering methods.

Abstract P3-06-05: Not presented

This abstract was not presented at the symposium.

Euxyl K 400: a new sensitizer in cosmetics

Euxyl K 400 is a preservative for cosmetics and toiletries containing 2 active ingredients, 1,2-dibromo-2,4-dicyanobutan and 2-phenoxyethanol. 2057 consecutive patients with contact dermatitis were patch tested with Euxyl K 400 2.5% pet. and ethanol. A positive patch test occurred in 24 patients (1.2%). The source of sensitization was traced in 8 patients to their cosmetics. Both leave-on and rinse-off products were responsible. Further patch tests with Euxyl K 400 0.5% pet. and phenoxyethanol 5% pet. were performed in 11 patients. A positive patch test to phenoxyethanol was detected in 1 of them. Only 3 patients showed a mild reaction to Euxyl K 400 0.5%. A provocative use test with a lotion preserved with Euxyl K 400 0.1% was positive in 5 of these 11 patients. Patients with Euxyl K 400 sensitivity showed a high prevalence of positive patch tests to other common ingredients of cosmetics. Since the use of Euxyl K 400 in cosmetic products is rapidly increasing, it should be included in the patch test series for patients with suspected cosmetic allergy.

Perioperative chemotherapy in the treatment of carcinoma of the uterine cervix

Two hundred forty-eight women from 1969-71 who underwent surgery for carcinoma of the cervix and were treated with triaziquone (0.2 mg i.v. daily) from day 2-5 after the operation, are compared to a group of 301 conventionally treated patients examined over the 3 following years. Survival rates after 5 years did not differ significantly between the 2 groups of patients, considered either globally or divided according to their clinical or surgical-pathological stage. The incidence of complications in the "treated" patients was not significantly higher, particularly considering local and general post-operative recovery. A prospective randomized study using drugs with a high cytotoxic activity in patients with tumors limited to the cervix and unfavorable prognostic factors, could in the future help evaluate the possibility of using surgical adjuvant chemotherapy in carcinoma of the cervix.

Comparative pharmacokinetic evaluation of ceftriaxone and cefotaxime in coincidence for short-term antimicrobial prophylaxis in surgery

In 48 patients undergoing elective gynecological, urological and otorhinolaryngological surgery a pharmacokinetic study after 1 g dose of ceftriaxone or cefotaxime was done. Concentrations of the two antibiotics were studied in interstitial fluid with the suction blister technique and in some tissues collected during the operation. The mean tissue levels were generally higher after ceftriaxone administration than after cefotaxime and for both drugs they were lower than the contemporary drug levels in interstitial fluid. However at the concentrations found almost all aerobic and anaerobic bacteria causing postoperative wound infections are inhibited.

Hysteroscopic reversible tubal sterilization

The Authors describe their experience with a new type of intratubal mechanical device to be inserted under hysteroscopic control. Up to present time, 1471 cycles without any other form of contraception have been observed. Although the promising results of this preliminary report in the field of hysteroscopic reversible tubal sterilization, the Authors underline that this new technique is still evolving and will be improved with further experience.

Chemotherapy of Choriocarcinoma

The department of Gynecology and Obstetrics of Florence University reports the following findings for the chemotherapy of gestational choriocarcinoma daring the period 1962–74. Sixteen cases, 11 of which were rated high risk cases, were given chemotherapy with MTX alone or in association with other cytotoxic agents. In the 12 surviving cases that may be considered the incidence of complete remission (from 4 to 13 years) is 67 %. Of the 8 cases rated as cured 3 were high risk cases at the beginning of treatment. Intermittent chemotherapy with MTX only was given by slow intravenous injection at doses of 3 to 4 mg/kg for 24–48 h followed from the 48th h by folinic acid treatment for 1–2 days. This schedule is recommended because of its negligible toxicity as a replacemen for intramuscular MTX in 5-day courses, which carries a fairly high risk of toxicity.

Evaluation of Cell-mediated Immunity in the Course of Primary Malignant Tumors of the Ovary. Cutaneous Reactivity

The present possibilities of clinically evaluating cell-mediated immune potential using skin reactivity to microbial protein antigens (streptokinase-streptodornase; tuberculin; formalin-killed parotitis virus) together with a contact sensitized such as dinitrochlorobenzene are examined. A single evaluation index for the set of cutireactions is proposed and, as a practical example, the delayed hypersensitivity data based on intradermal and patch tests in 41 cases of primary malignant tumor of the ovary are reported. There is a definite correlation between immune impairment and cancer spread, with a survival prognosis value even in initial cases.