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Keyloun JW, Le TD, Moffatt LT, Orfeo T, McLawhorn MM, Bravo MC, Tejiram S, Shupp JW, Pusateri AE. Comparison of Rapid-, Kaolin-, and Native-TEG Parameters in Burn Patient Cohorts With Acute Burn-induced Coagulopathy and Abnormal Fibrinolytic Function. J Burn Care Res 2024; 45:70-79. [PMID: 37837656 PMCID: PMC10768763 DOI: 10.1093/jbcr/irad152] [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: 03/24/2023] [Indexed: 10/16/2023]
Abstract
Although use of thromboelastography (TEG) to diagnose coagulopathy and guide clinical decision-making is increasing, relative performance of different TEG methods has not been well-defined. Rapid-TEG (rTEG), kaolin-TEG (kTEG), and native-TEG (nTEG) were performed on blood samples from burn patients presenting to a regional center from admission to 21 days. Patients were categorized by burn severity, mortality, and fibrinolytic phenotypes (Shutdown [SD], Physiologic [PHYS], and Hyperfibrinolytic [HF]). Manufacturer ranges and published TEG cutoffs were examined. Concordance correlations (Rc) of TEG parameters (R, α-angle, maximum amplitude [MA], LY30) measured agreement and Cohen's Kappa (κ) determined interclass reliability. Patients (n = 121) were mostly male (n = 84; 69.4%), with median age 40 years, median TBSA burn 13%, and mortality 17% (n = 21). Severe burns (≥40% TBSA) were associated with lower admission α-angle for rTEG (P = .03) and lower MA for rTEG (P = .02) and kTEG (P = .01). MA was lower in patients who died (nTEG, P = .04; kTEG, P = .02; rTEG, P = .003). Admission HF was associated with increased mortality (OR, 10.45; 95% CI, 2.54-43.31, P = .001) on rTEG only. Delayed SD was associated with mortality using rTEG and nTEG (OR 9.46; 95% CI, 1.96-45.73; P = .005 and OR, 6.91; 95% CI, 1.35-35.48; P = .02). Admission TEGs showed poor agreement on R-time (Rc, 0.00-0.56) and α-angle (0.40 to 0.55), and moderate agreement on MA (0.67-0.81) and LY30 (0.72-0.93). Interclass reliability was lowest for R-time (κ, -0.07 to 0.01) and α-angle (-0.06 to 0.17) and highest for MA (0.22-0.51) and LY30 (0.29-0.49). Choice of TEG method may impact clinical decision-making. rTEG appeared most sensitive in parameter-specific associations with injury severity, abnormal fibrinolysis, and mortality.
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Affiliation(s)
- John W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC 20010, USA
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC 20010, USA
| | - Tuan D Le
- Research Directorate, U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Department of Epidemiology and Biostatistics, University of Texas Tyler School of Medicine, Tyler, TX 75708, USA
| | - Lauren T Moffatt
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC 20010, USA
- Department of Biochemistry, Georgetown University, Washington, DC 20057, USA
| | - Thomas Orfeo
- Department of Biochemistry, College of Medicine, University of Vermont, Colchester, VT 05405, USA
| | - Melissa M McLawhorn
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC 20010, USA
| | - Maria-Cristina Bravo
- Department of Biochemistry, College of Medicine, University of Vermont, Colchester, VT 05405, USA
| | - Shawn Tejiram
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC 20010, USA
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC 20010, USA
- Department of Surgery, Georgetown University, Washington, DC 20057, USA
| | - Anthony E Pusateri
- Combat Casualty Care and Operational Medicine Directorate, Naval Medical Research Unit San Antonio, JBSA Fort Sam Houston, TX 78234, USA
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
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Pusateri AE, Morgan CG, Neidert LE, Tiller MM, Glaser JJ, Weiskopf RB, Ebrahim I, Stassen W, Rambharose S, Mahoney SH, Wallis LA, Hollis EM, Delong GT, Cardin S. Safety of Bioplasma FDP and Hemopure in rhesus macaques after 30% hemorrhage. Trauma Surg Acute Care Open 2024; 9:e001147. [PMID: 38196929 PMCID: PMC10773430 DOI: 10.1136/tsaco-2023-001147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/03/2023] [Indexed: 01/11/2024] Open
Abstract
Objectives Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM). Methods After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology. Results Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP. Conclusion There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function. Level of evidence Not applicable.
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Affiliation(s)
| | - Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Michael M Tiller
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Jacob J Glaser
- Providence Regional Medical Center, Everett, Washington, USA
| | - Richard B Weiskopf
- Department of Anesthesia and Perioperative Medcine, University of California San Francisco, San Francisco, California, USA
| | - Ismaeel Ebrahim
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Willem Stassen
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Sanjeev Rambharose
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Scott H Mahoney
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Lee A Wallis
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Ewell M Hollis
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Gerald T Delong
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Sylvain Cardin
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
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Stassen W, Wylie C, Craig W, Ebrahim I, Mahoney SH, Pusateri AE, Rambharose S, van Koningsbruggen C, Weiskopf RB, Wallis LA. The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study. PREHOSP EMERG CARE 2023:1-7. [PMID: 37713658 DOI: 10.1080/10903127.2023.2259998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.
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Affiliation(s)
- Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Craig Wylie
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Wesley Craig
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Ismaeel Ebrahim
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Scott H Mahoney
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Anthony E Pusateri
- Naval Medical Research Unit-San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Sanjeev Rambharose
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | | | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
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Le TD, Gurney JM, Singh KP, Nessen SC, Schneider ALC, Agimi Y, Bebarta VS, Herson PS, Stout KC, Cardin S, Crowder AT, Ling GSF, Stackle ME, Pusateri AE. Trends in Traumatic Brain Injury Among U.S. Service Members Deployed in Iraq and Afghanistan, 2002-2016. Am J Prev Med 2023; 65:230-238. [PMID: 36870787 DOI: 10.1016/j.amepre.2023.01.043] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a major health issue for service members deployed and is more common in recent conflicts; however, a thorough understanding of risk factors and trends is not well described. This study aims to characterize the epidemiology of TBI in U.S. service members and the potential impacts of changes in policy, care, equipment, and tactics over the 15 years studied. METHODS Retrospective analysis of U.S. Department of Defense Trauma Registry data (2002-2016) was performed on service members treated for TBI at Role 3 medical treatment facilities in Iraq and Afghanistan. Risk factors and trends in TBI were examined in 2021 using Joinpoint regression and logistic regression. RESULTS Nearly one third of 29,735 injured service members (32.4%) reaching Role 3 medical treatment facilities had TBI. The majority sustained mild (75.8%), followed by moderate (11.6%) and severe (10.6%) TBI. TBI proportion was higher in males than in females (32.6% vs 25.3%; p<0.001), in Afghanistan than in Iraq (43.8% vs 25.5%; p<0.001), and in battle than in nonbattle (38.6% vs 21.9%; p<0.001). Patients with moderate or severe TBI were more likely to have polytrauma (p<0.001). TBI proportion increased over time, primarily in mild TBI (p=0.02), slightly in moderate TBI (p=0.04), and most rapidly between 2005 and 2011, with a 2.48% annual increase. CONCLUSIONS One third of injured service members at Role 3 medical treatment facilities experienced TBI. Findings suggest that additional preventive measures may decrease TBI frequency and severity. Clinical guidelines for field management of mild TBI may reduce the burden on evacuation and hospital systems. Additional capabilities may be needed for military field hospitals.
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Affiliation(s)
- Tuan D Le
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas; Department of Epidemiology and Biostatistics, UT Tyler School of Medicine, The University of Texas at Tyler Health Science Center, Tyler, Texas.
| | - Jennifer M Gurney
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas; Joint Trauma System, Fort Sam Houston, Texas
| | - Karan P Singh
- Department of Epidemiology and Biostatistics, UT Tyler School of Medicine, The University of Texas at Tyler Health Science Center, Tyler, Texas
| | | | - Andrea L C Schneider
- Division of Neurocritical Care, Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Yll Agimi
- Defense and Veterans Brain Injury Center, Defense Health Agency, Silver Spring, Maryland
| | - Vikhyat S Bebarta
- Department of Emergency Medicine and Center for COMBAT Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; CU Center for COMBAT Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Anesthesiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Paco S Herson
- Department of Anesthesiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Katharine C Stout
- Defense and Veterans Brain Injury Center, Defense Health Agency, Silver Spring, Maryland
| | - Sylvain Cardin
- Naval Medical Research Unit-San Antonio TX, Fort Sam Houston, Texas
| | - Alicia T Crowder
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Geoffrey S F Ling
- Department of Neurology, School of Medicine, John Hopkins University, Baltimore, Maryland
| | - Mark E Stackle
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Anthony E Pusateri
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas; Department of Neurology, School of Medicine, John Hopkins University, Baltimore, Maryland
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Morgan CG, Neidert LE, Ozuna KM, Glaser JJ, Pusateri AE, Tiller MM, Cardin S. Pre-Hospital Plasma is Non-Inferior to Whole Blood for Restoration of Cerebral Oxygenation in a Rhesus Macaque Model of Traumatic Shock and Hemorrhage. Shock 2023:00024382-990000000-00207. [PMID: 37179251 DOI: 10.1097/shk.0000000000002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Traumatic shock and hemorrhage (TSH) is a leading cause of preventable death in military and civilian populations. Utilizing a TSH model, we compared Plasma with whole blood (WB) as pre-hospital interventions, evaluating restoration of cerebral tissue oxygen saturation (CrSO2), systemic hemodynamics, colloid osmotic pressure (COP) and arterial lactate, hypothesizing plasma would function in a non-inferior capacity to WB, despite dilution of hemoglobin (Hgb). METHODS Ten anesthetized male rhesus macaques underwent TSH before randomization to receive a bolus of O(-) WB or AB(+) Plasma at T0. At T60, injury repair and shed blood (SB) to maintain mean arterial pressure (MAP) > 65 mmHg began, simulating hospital arrival. Hematologic data and vital signs were analyzed via t-test and two-way repeated measures ANOVA, data presented as mean ± standard deviation, significance = P < 0.05. RESULTS There were no significant group differences for shock time, SB volume or hospital SB. At T0, MAP and CrSO2 significantly declined from baseline, though not between groups, normalizing to baseline by T10. COP declined significantly in each group from baseline at T0 but restored by T30, despite significant differences in Hgb (WB 11.7 ± 1.5 v Plasma 6.2 ± 0.8 g/dL). Peak lactate at T30 was significantly higher than baseline in both groups (WB 6.6 ± 4.9 v Plasma 5.7 ± 1.6 mmol/L) declining equivalently by T60. CONCLUSIONS Plasma restored hemodynamic support and CrSO2, in a capacity not inferior to WB, despite absence of additional Hgb supplementation. This was substantiated via return of physiologic COP levels, restoring oxygen delivery to microcirculation, demonstrating the complexity of restoring oxygenation from TSH beyond simply increasing oxygen carrying capacity.
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Yang Z, Nunn MA, Le TD, Simovic MO, Edsall PR, Liu B, Barr JL, Lund BJ, Hill-Pryor CD, Pusateri AE, Cancio LC, Li Y. Immunopathology of terminal complement activation and complement C5 blockade creating a pro-survival and organ-protective phenotype in trauma. Br J Pharmacol 2023; 180:422-440. [PMID: 36251578 PMCID: PMC10100417 DOI: 10.1111/bph.15970] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/24/2022] [Accepted: 09/17/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Traumatic haemorrhage (TH) is the leading cause of potentially preventable deaths that occur during the prehospital phase of care. No effective pharmacological therapeutics are available for critical TH patients yet. Here, we identify terminal complement activation (TCA) as a therapeutic target in combat casualties and evaluate the efficacy of a TCA inhibitor (nomacopan) on organ damage and survival in vivo. EXPERIMENTAL APPROACH Complement activation products and cytokines were analysed in plasma from 54 combat casualties. The correlations between activated complement pathway(s) and the clinical outcomes in trauma patients were assessed. Nomacopan was administered to rats subjected to lethal TH (blast injury and haemorrhagic shock). Effects of nomacopan on TH were determined using survival rate, organ damage, physiological parameters, and laboratory profiles. KEY RESULTS Early TCA was associated with systemic inflammatory responses and clinical outcomes in this trauma cohort. Lethal TH in the untreated rats induced early TCA that correlated with the severity of tissue damage and mortality. The addition of nomacopan to a damage-control resuscitation (DCR) protocol significantly inhibited TCA, decreased local and systemic inflammatory responses, improved haemodynamics and metabolism, attenuated tissue and organ damage, and increased survival. CONCLUSION AND IMPLICATIONS Previous findings of our and other groups revealed that early TCA represents a rational therapeutic target for trauma patients. Nomacopan as a pro-survival and organ-protective drug, could emerge as a promising adjunct to DCR that may significantly reduce the morbidity and mortality in severe TH patients while awaiting transport to critical care facilities.
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Affiliation(s)
- Zhangsheng Yang
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | | | - Tuan D Le
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Milomir O Simovic
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA.,The Geneva Foundation, Tacoma, Washington, USA
| | - Peter R Edsall
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Bin Liu
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Johnny L Barr
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Brian J Lund
- 59th Medical Wing Operational Medicine, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | | | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA
| | - Yansong Li
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas, USA.,The Geneva Foundation, Tacoma, Washington, USA
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Le TD, Cook AD, Le TT, Keyloun JW, Detwiler PW, Ledlow GR, Pusateri AE, Singh KP. Trends in Traumatic Brain Injury Related to Consumer Products Among U.S. School-aged Children Between 2000 and 2019. Am J Prev Med 2022; 63:469-477. [PMID: 36137667 DOI: 10.1016/j.amepre.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/30/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Consumer product‒related traumatic brain injury in children is common, but long-term trends have not been well characterized. Understanding the long-term trends in consumer product‒related traumatic brain injury may inform prevention efforts. The study objective is to examine the trends in consumer product‒related traumatic brain injury in school-aged children. METHODS Data were extracted from the National Electronic Injury Surveillance System-All Injury Program for initial emergency department visits for consumer product‒related traumatic brain injury (2000-2019) in school-aged children and analyzed in 2021. RESULTS Approximately 6.2 million children presented to emergency department with consumer product‒related traumatic brain injury during 2000-2019. Consumer product‒related traumatic brain injury increased from 4.5% of overall consumer product‒emergency department visits in 2000 to 12.3% in 2019, and its incidence rate (cases per 100,000 population) was higher in males (681.2; 95% CI=611.2, 751.2) than in females (375.8; 95% CI=324.1, 427.6). The annual percentage change in consumer product‒related traumatic brain injury was 3.6% from 2000 to 2008, 13.3% from 2008 to 2012, and ‒2.0% through 2019. Average annual percentage change was higher in females (5.1%; 95% CI=3.4, 6.8) than in males (2.8%; 95% CI=1.6, 3.9). Consumer product‒related traumatic brain injury increased from 2000 to 2012 in females and then remained stable. In males, annual percentage change increased from 2008 to 2012 and then declined through 2019. CONCLUSIONS Traumatic brain injury incidence rate in school-aged children increased from 2000 to 2019, peaked in 2012, and then declined in males but not in females. Percentage increases were highest in females. Prevention strategies should continue, with a specific focus on reducing consumer product‒related traumatic brain injury in female children.
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Affiliation(s)
- Tuan D Le
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas at Tyler Health Science Center, Tyler, Texas; Research Directorate, U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Sam Houston, Texas.
| | - Alan D Cook
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas at Tyler Health Science Center, Tyler, Texas; Department of Surgery, The University of Texas at Tyler Health Science Center and UT Health East Texas, Tyler, Texas; The Center for Trauma Research, The University of Texas at Tyler Health Science Center and UT Health East Texas, Tyler, Texas
| | - Tony T Le
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas at Tyler Health Science Center, Tyler, Texas; School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John W Keyloun
- Department of Surgery, Georgetown University Medical School, Washington, District of Columbia
| | - Paul W Detwiler
- Department of Surgery, The University of Texas at Tyler Health Science Center and UT Health East Texas, Tyler, Texas; The Center for Trauma Research, The University of Texas at Tyler Health Science Center and UT Health East Texas, Tyler, Texas
| | - Gerald R Ledlow
- Department of Healthcare Policy, Economics and Management, School of Community and Rural Health, The University of Texas at Tyler Health Science Center, Tyler, Texas
| | - Anthony E Pusateri
- Naval Medical Research Unit - San Antonio, JBSA-Fort Sam Houston, Sam Houston, Texas
| | - Karan P Singh
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas at Tyler Health Science Center, Tyler, Texas
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Spinella PC, Bochicchio K, Thomas KA, Staudt A, Shea SM, Pusateri AE, Schuerer D, Levy JH, Cap AP, Bochicchio G. The risk of thromboembolic events with early intravenous 2- and 4-g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double-blind, placebo-controlled, single-center trial. Transfusion 2022; 62 Suppl 1:S139-S150. [PMID: 35765921 DOI: 10.1111/trf.16962] [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] [Received: 03/04/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Screening for the risk of thromboembolism (TE) due to tranexamic acid (TXA) in patients with severe traumatic injury has not been performed in randomized clinical trials. Our objective was to determine if TXA dose was independently-associated with thromboembolism. STUDY DESIGN AND METHODS This is a secondary analysis of a single-center, double-blinded, randomized controlled trial comparing placebo to a 2-g or 4-g intravenous TXA bolus dose in trauma patients with severe injury. We used multivariable discrete-time Cox regression models to identify associations with risk for thromboembolic events within 30 days post-enrollment. Event curves were created using discrete-time Cox regression. RESULTS There were 50 patients in the placebo group, 49 in the 2-g, and 50 in the 4-g TXA group. In adjusted analyses for thromboembolism, a 2-g dose of TXA had an hazard ratio (HR, 95% confidence interval [CI]) of 3.20 (1.12-9.11) (p = .029), and a 4-g dose of TXA had an HR (95% CI) of 5.33 (1.94-14.63) (p = .001). Event curves demonstrated a higher probability of thromboembolism for both doses of TXA compared to placebo. Other parameters independently associated with thromboembolism include time from injury to TXA administration, body mass index, and total blood products transfused. DISCUSSION In patients with severe traumatic injury, there was a dose-dependent increase in the risk of at least one thromboembolic event with TXA. TXA should not be withheld, but thromboembolism screening should be considered for patients receiving a dose of at least 2-g TXA intravenously for traumatic hemorrhage.
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Affiliation(s)
- Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelly Bochicchio
- Department of Surgery, Division of Acute Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kimberly A Thomas
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amanda Staudt
- Clinical Research Support Branch, The Geneva Foundation, Fort Sam Houston, Texas, USA
| | - Susan M Shea
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Douglas Schuerer
- Department of Surgery, Division of Acute Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina USA, Durham, North Carolina-NC, 27710, USA
| | - Andrew P Cap
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Grant Bochicchio
- Department of Surgery, Division of Acute Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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9
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Le TD, Gurney JM, Akers KS, Chung KK, Singh KP, Wang HC, Stackle ME, Pusateri AE. Analysis of Nonbattle Deaths Among U.S. Service Members in the Deployed Environment. Ann Surg 2021; 274:e445-e451. [PMID: 34238813 DOI: 10.1097/sla.0000000000005047] [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: 11/26/2022]
Abstract
OBJECTIVE Describe etiologies and trends in non-battle deaths (NBD) among deployed U.S. service members to identify areas for prevention. BACKGROUND Injuries in combat are categorized as battle (result of hostile action) or nonbattle related. Previous work found that one-third of injured US military personnel in Iraq and Afghanistan had nonbattle injuries and emphasized prevention. NBD have not yet been characterized. METHODS U.S. military casualty data for Iraq and Afghanistan from 2001 to 2014 were obtained from the Defense Casualty Analysis System (DCAS) and the Department of Defense Trauma Registry (DoDTR). Two databases were used because DoDTR does not capture prehospital deaths, while DCAS does not contain clinical details. Nonbattle injuries and NBD were identified, etiologies classified, and NBD trends were assessed using a weighted moving average and time-series analysis with autoregressive integrated moving average. Future NBD rates were forecast. RESULTS DCAS recorded 59,799 casualties; 21.0% (n = 1431) of all deaths (n = 6745) were NBD. DoDTR recorded 29,958 casualties; 11.5% (n = 206) of all deaths (n = 1788) were NBD. After early fluctuations, NBD rates for both Iraq and Afghanistan stabilized at approximately 21%. Leading causes of NBD were gunshot wounds and vehicle accidents, accounting for 66%. Approximately 25% was self-inflicted. A 24% NBD rate was forecasted from 2015 through 2025. CONCLUSIONS Approximately 1 in 5 deaths were NBD. The majority were potentially preventable, including a significant proportion of self-inflicted injuries. A single comprehensive data repository would facilitate future mortality monitoring and performance improvement. These data may assist military leaders with implementing targeted safety strategies.
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Affiliation(s)
- Tuan D Le
- Research Directorate, U.S. Army Institute of Surgical Research, JBSA - Fort Sam Houston, Texas
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Jennifer M Gurney
- Research Directorate, U.S. Army Institute of Surgical Research, JBSA - Fort Sam Houston, Texas
- Joint Trauma System, JBSA - Fort Sam Houston, Texas
| | - Kevin S Akers
- Research Directorate, U.S. Army Institute of Surgical Research, JBSA - Fort Sam Houston, Texas
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Karan P Singh
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Heuy-Ching Wang
- Naval Medical Research Center, JBSA - Fort Sam Houston, Texas
| | - Mark E Stackle
- Research Directorate, U.S. Army Institute of Surgical Research, JBSA - Fort Sam Houston, Texas
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10
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Edwards TH, Rizzo JA, Pusateri AE. Hemorrhagic shock and hemostatic resuscitation in canine trauma. Transfusion 2021; 61 Suppl 1:S264-S274. [PMID: 34269447 DOI: 10.1111/trf.16516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022]
Abstract
Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, Joint Base San Antonio - Fort Sam Houston, Texas, USA
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11
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Keyloun JW, Le TD, Pusateri AE, Ball RL, Carney BC, Orfeo T, Brummel-Ziedins KE, Bravo MC, McLawhorn MM, Moffatt LT, Shupp JW. Circulating Syndecan-1 and Tissue Factor Pathway Inhibitor, Biomarkers of Endothelial Dysfunction, Predict Mortality in Burn Patients. Shock 2021; 56:237-244. [PMID: 33394974 PMCID: PMC8284378 DOI: 10.1097/shk.0000000000001709] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/27/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the association between burn injury and admission plasma levels of Syndecan-1 (SDC-1) and Tissue Factor Pathway Inhibitor (TFPI), and their ability to predict 30-day mortality. BACKGROUND SDC-1 and TFPI are expressed by vascular endothelium and shed into the plasma as biomarkers of endothelial damage. Admission plasma biomarker levels have been associated with morbidity and mortality in trauma patients, but this has not been well characterized in burn patients.Methods: This cohort study enrolled burn patients admitted to a regional burn center between 2013 and 2017. Blood samples were collected within 4 h of admission and plasma SDC-1 and TFPI were quantified by ELISA. Demographics and injury characteristics were collected prospectively. The primary outcome was 30-day in-hospital mortality. RESULTS Of 158 patients, 74 met inclusion criteria. Most patients were male with median age of 41.5 years and burn TBSA of 20.5%. The overall mortality rate was 20.3%. Admission SDC-1 and TFPI were significantly higher among deceased patients. Plasma SDC-1 >34 ng/mL was associated with a 32-times higher likelihood of mortality [OR: 32.65 (95% CI, 2.67-399.78); P = 0.006] and a strong predictor of mortality (area under the ROC [AUROC] 0.92). TFPI was associated with a nine-times higher likelihood of mortality [OR: 9.59 (95% CI, 1.02-89.75); P = 0.002] and a fair predictor of mortality (AUROC 0.68). CONCLUSIONS SDC-1 and TFPI are associated with a higher risk of 30-day mortality. We propose the measurement of SDC-1 on admission to identify burn patients at high risk of mortality. However, further investigation with a larger sample size is warranted.
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Affiliation(s)
- John W. Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Tuan D. Le
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, University of Texas Health Science Center, Tyler, Texas
| | | | - Robert L. Ball
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Bonnie C. Carney
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry, Georgetown University, Washington, DC
| | - Thomas Orfeo
- Department of Surgery, Georgetown University, Washington, DC
| | | | - Maria C. Bravo
- Department of Surgery, Georgetown University, Washington, DC
| | - Melissa M. McLawhorn
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Lauren T. Moffatt
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry, Georgetown University, Washington, DC
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Jeffrey W. Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry, Georgetown University, Washington, DC
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Burlington, Vermont
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12
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Keyloun JW, Le TD, Brummel-Ziedins KE, Mclawhorn MM, Bravo MC, Orfeo T, Johnson LS, Moffatt LT, Pusateri AE, Shupp JW. Inhalation Injury is Associated with Endotheliopathy and Abnormal Fibrinolytic Phenotypes in Burn Patients: A Cohort Study. J Burn Care Res 2021; 43:432-439. [PMID: 34089618 PMCID: PMC8946676 DOI: 10.1093/jbcr/irab102] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Burn injury is associated with endothelial dysfunction and coagulopathy and concomitant inhalation injury increases morbidity and mortality. The aim of this work is to identify associations between inhalation injury (IHI), coagulation homeostasis, vascular endothelium, and clinical outcomes in burn patients. One-hundred and twelve patients presenting to a regional burn center were included in this retrospective cohort study. Whole blood was collected at set intervals from admission through 24 hours and underwent viscoelastic assay with rapid TEG (rTEG). Syndecan-1 (SDC-1) on admission was quantified by ELISA. Patients were grouped by the presence (n=28) or absence (n=84) of concomitant IHI and rTEG parameters, fibrinolytic phenotypes, SDC-1, and clinical outcomes were compared. Of the 112 thermally injured patients, 28 (25%) had IHI. Most patients were male (68.8%) with a median age of 40 (IQR, 29-57) years. Patients with IHI had higher overall mortality (42.68% vs. 8.3%; p<0.0001). rTEG LY30 was lower in patients with IHI at hours 4 and 12 (p<0.05). There was a pattern of increased abnormal fibrinolytic phenotypes among IHI patients. There was a greater proportion of IHI patients with endotheliopathy (SDC-1 > 34 ng/mL) (64.7% vs. 26.4%; p=0.008). There was a pattern of increased mortality among patients with inhalation injury and endotheliopathy (0% vs. 72.7%; p=0.004). Significant differences between patients with and without IHI were found in measures assessing fibrinolytic potential and endotheliopathy. Mortality was associated with abnormal fibrinolysis, endotheliopathy, and inhalation injury. However, the extent to which IHI associated dysfunction is independent of TBSA burn size remains to be elucidated.
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Affiliation(s)
- John W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Tuan D Le
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, TX
| | | | - Melissa M Mclawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Maria C Bravo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Thomas Orfeo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Laura S Johnson
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
| | | | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
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13
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Edwards TH, Pusateri AE, Mays EL, Bynum JA, Cap AP. Lessons Learned From the Battlefield and Applicability to Veterinary Medicine - Part 2: Transfusion Advances. Front Vet Sci 2021; 8:571370. [PMID: 34026881 PMCID: PMC8138582 DOI: 10.3389/fvets.2021.571370] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Since the inception of recent conflicts in Afghanistan and Iraq, transfusion practices in human military medicine have advanced considerably. Today, US military physicians recognize the need to replace the functionality of lost blood in traumatic hemorrhagic shock and whole blood is now the trauma resuscitation product of choice on the battlefield. Building on wartime experiences, military medicine is now one of the country's strongest advocates for the principle of hemostatic resuscitation using whole blood or balanced blood components as the primary means of resuscitation as early as possibly following severe trauma. Based on strong evidence to support this practice in human combat casualties and in civilian trauma care, military veterinarians strive to practice similar hemostatic resuscitation for injured Military Working Dogs. To this end, canine whole blood has become increasingly available in forward environments, and non-traditional storage options for canine blood and blood components are being explored for use in canine trauma. Blood products with improved shelf-life and ease of use are not only useful for military applications, but may also enable civilian general and specialty practices to more easily incorporate hemostatic resuscitation approaches to canine trauma care.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Anthony E Pusateri
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Erin Long Mays
- Veterinary Specialty Services, Manchester, MO, United States
| | - James A Bynum
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
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14
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Pusateri AE, Le TD, Keyloun JW, Moffatt LT, Orfeo T, Brummel-Ziedins KE, McLawhorn MM, Callcut RA, Shupp JW. Early abnormal fibrinolysis and mortality in patients with thermal injury: a prospective cohort study. BJS Open 2021; 5:6248890. [PMID: 33893737 DOI: 10.1093/bjsopen/zrab017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/03/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Abnormal fibrinolysis early after injury has been associated with increased mortality in trauma patients, but no studies have addressed patients with burn injury. This prospective cohort study aimed to characterize fibrinolytic phenotypes in burn patients and to see if they were associated with mortality. METHODS Patients presenting to a regional burn centre within 4 h of thermal injury were included. Blood was collected for sequential viscoelastic measurements using thromboelastography (RapidTEG™) over 12 h. The percentage decrease in clot strength 30 min after the time of maximal clot strength (LY30) was used to categorize patients into hypofibrinolytic/fibrinolytic shutdown (SD), physiological (PHYS) and hyperfibrinolytic (HF) phenotypes. Injury characteristics, demographics and outcomes were compared. RESULTS Of 115 included patients, just over two thirds were male. Overall median age was 40 (i.q.r. 28-57) years and median total body surface area (TBSA) burn was 13 (i.q.r. 6-30) per cent. Some 42 (36.5 per cent) patients had severe burns affecting over 20 per cent TBSA. Overall mortality was 18.3 per cent. At admission 60.0 per cent were PHYS, 30.4 per cent were SD and 9.6 per cent HF. HF was associated with increased risk of mortality on admission (odds ratio 12.61 (95 per cent c.i. 1.12 to 142.57); P = 0.041) but not later during the admission when its incidence also decreased. Admission SD was not associated with mortality, but incidence increased and by 4 h and beyond, SD was associated with increased mortality, compared with PHYS (odds ratio 8.27 (95 per cent c.i. 1.16 to 58.95); P = 0.034). DISCUSSION Early abnormal fibrinolytic function is associated with mortality in burn patients.
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Affiliation(s)
- A E Pusateri
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - T D Le
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, Texas, USA
| | - J W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - L T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,Department of Biochemistry, Georgetown University, Washington, DC, USA
| | - T Orfeo
- Department of Biochemistry, College of Medicine, University of Vermont, Colchester, Vermont, USA
| | - K E Brummel-Ziedins
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - M M McLawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - R A Callcut
- Department of Surgery, University of California Davis School of Medicine, Sacramento, California, USA
| | - J W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,Department of Surgery, Georgetown University, Washington, DC, USA
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15
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Edwards TH, Darlington DN, Pusateri AE, Keesee JD, Ruiz DD, Little JS, Parker JS, Cap AP. Hemostatic capacity of canine chilled whole blood over time. J Vet Emerg Crit Care (San Antonio) 2021; 31:239-246. [PMID: 33709546 DOI: 10.1111/vec.13055] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 07/10/2019] [Accepted: 08/12/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the hemostatic potential of canine chilled whole blood maintained at clinically relevant storage conditions. DESIGN In vitro experimental study. SETTING Government blood and coagulation research laboratory and government referral veterinary hospital. ANIMALS Ten healthy Department of Defense military working dogs. INTERVENTIONS One unit of fresh whole blood was collected from each of 10 military working dogs using aseptic technique. Blood was maintained in a medical-grade refrigerator for 28 days at 4°C (39°F) and analyzed before refrigeration (day 0) and after (days 2, 4, 7, 9, 11, 14, 21, and 28). MEASUREMENTS AND MAIN RESULTS Ten units of canine blood were analyzed with whole blood platelet aggregation, thromboelastography, CBC, biochemical analysis, blood gas, and prothrombin/activated partial thromboplastin/fibrinogen assay. Clotting strength of chilled blood was maintained up to 21 days despite significant decreases in platelet aggregation to ADP, collagen, or γ-thrombin, significant prolongation of prothrombin and activated partial thromboplastin times, and reduced speed of clot formation (K time, alpha angle). Fibrinogen concentration, WBC, RBC, and platelet counts did not change over time. CONCLUSIONS Chilled canine whole blood loses a small percentage of clot strength through 21 days of refrigerated storage. Further research is needed to determine if this hemostatic potential is clinically relevant in hemorrhaging dogs who require surgical intervention or are exposed to traumatic events.
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Affiliation(s)
- Thomas H Edwards
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, Texas, USA
| | - Daniel N Darlington
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, Texas, USA
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, Texas, USA
| | - Jeffrey D Keesee
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, Texas, USA
| | - Daikor D Ruiz
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, Texas, USA
| | - Joshua S Little
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, Texas, USA
| | - Jacquelyn S Parker
- Department of Defense Military Working Dog Veterinary Service, Joint Base San Antonio-Lackland, Texas, USA
| | - Andrew P Cap
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, Texas, USA
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16
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Holcomb JB, Moore EE, Sperry JL, Jansen JO, Schreiber MA, Del Junco DJ, Spinella PC, Sauaia A, Brohi K, Bulger EM, Cap AP, Hess JR, Jenkins D, Lewis RJ, Neal MD, Newgard C, Pati S, Pusateri AE, Rizoli S, Russell RT, Shackelford SA, Stein DM, Steiner ME, Wang H, Ward KR, Young P. Evidence-Based and Clinically Relevant Outcomes for Hemorrhage Control Trauma Trials. Ann Surg 2021; 273:395-401. [PMID: 33065652 DOI: 10.1097/sla.0000000000004563] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [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: 12/18/2022]
Abstract
OBJECTIVE To address the clinical and regulatory challenges of optimal primary endpoints for bleeding patients by developing consensus-based recommendations for primary clinical outcomes for pivotal trials in patients within 6 categories of significant bleeding, (1) traumatic injury, (2) intracranial hemorrhage, (3) cardiac surgery, (4) gastrointestinal hemorrhage, (5) inherited bleeding disorders, and (6) hypoproliferative thrombocytopenia. BACKGROUND A standardized primary outcome in clinical trials evaluating hemostatic products and strategies for the treatment of clinically significant bleeding will facilitate the conduct, interpretation, and translation into clinical practice of hemostasis research and support alignment among funders, investigators, clinicians, and regulators. METHODS An international panel of experts was convened by the National Heart Lung and Blood Institute and the United States Department of Defense on September 23 and 24, 2019. For patients suffering hemorrhagic shock, the 26 trauma working-group members met for almost a year, utilizing biweekly phone conferences and then an in-person meeting, evaluating the strengths and weaknesses of previous high quality studies. The selection of the recommended primary outcome was guided by goals of patient-centeredness, expected or demonstrated sensitivity to beneficial treatment effects, biologic plausibility, clinical and logistical feasibility, and broad applicability. CONCLUSIONS For patients suffering hemorrhagic shock, and especially from truncal hemorrhage, the recommended primary outcome was 3 to 6-hour all-cause mortality, chosen to coincide with the physiology of hemorrhagic death and to avoid bias from competing risks. Particular attention was recommended to injury and treatment time, as well as robust assessments of multiple safety related outcomes.
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Affiliation(s)
- John B Holcomb
- Center for Injury Science, Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Distinguished Professor, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, CO
| | - Jason L Sperry
- Pittsburgh Trauma Research Center and the Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jan O Jansen
- Division of Acute Care Surgery, Center for Injury Science, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Angela Sauaia
- Department of Public Health and Surgery, University of Colorado Denver, School of Public health, University of Colorado, Denver, CO
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | | | - Andrew P Cap
- US Army Institute of Surgical Research, Uniformed Services University, Ft Sam Houston, TX
| | - John R Hess
- Department of Laboratory Medicine and Hematology, University of Washington School of Medicine, Seattle, WA
| | - Donald Jenkins
- Department of Surgery, Division of Trauma and Emergency Surgery, UT Health, San Antonio, TX
| | - Roger J Lewis
- Berry Consultants LLC, Austin, TX; Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center and the Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Shibani Pati
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, TX
| | - Sandro Rizoli
- Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Robert T Russell
- Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL
| | | | - Deborah M Stein
- Zuckerberg San Francisco General Hospital and Trauma Center, UCSF, San Francisco, CA
| | - Marie E Steiner
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Division of Pediatric Critical Care Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Henry Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston TX
| | - Kevin R Ward
- Emergency Medicine and Biomedical Engineering, Executive Director, Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI
| | - Pampee Young
- American Red Cross, Biomedical Division, Washington, D.C., Vanderbilt University Medical Center, Nashville, TN
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Edwards TH, Dubick MA, Palmer L, Pusateri AE. Lessons Learned From the Battlefield and Applicability to Veterinary Medicine-Part 1: Hemorrhage Control. Front Vet Sci 2021; 7:571368. [PMID: 33521075 PMCID: PMC7841008 DOI: 10.3389/fvets.2020.571368] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
In humans, the leading cause of potentially preventable death on the modern battlefield is undoubtedly exsanguination from massive hemorrhage. The US military and allied nations have devoted enormous effort to combat hemorrhagic shock and massive hemorrhage. This has yielded numerous advances designed to stop bleeding and save lives. The development of extremity, junctional and truncal tourniquets applied by first responders have saved countless lives both on the battlefield and in civilian settings. Additional devices such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and intraperitoneal hemostatic foams show great promise to address control the most difficult forms (non-compressible) of hemorrhage. The development of next generation hemostatic dressings has reduced bleeding both in the prehospital setting as well as in the operating room. Furthermore, the research and fielding of antifibrinolytics such as tranexamic acid have shown incredible promise to ameliorate the effects of acute traumatic coagulopathy which has led to significant morbidity and mortality in service members. Advances from lessons learned on the battlefield have numerous potential parallels in veterinary medicine and these lessons are ripe for translation to veterinary medicine.
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Affiliation(s)
- Thomas H Edwards
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Michael A Dubick
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Lee Palmer
- Special Forces Group, Alabama Army National Guard, Auburn, AL, United States
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
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18
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Edwards TH, Meledeo MA, Peltier GC, Ruiz DD, Henderson AF, Travieso S, Pusateri AE. Effects of refrigerated storage on hemostatic stability of four canine plasma products. Am J Vet Res 2020; 81:964-972. [PMID: 33251844 DOI: 10.2460/ajvr.81.12.964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess clotting times, coagulation factor activities, sterility, and thromboelastographic parameters of liquid plasma (LP), thawed fresh frozen plasma (FFP-T), and 2 novel formulations of freeze-dried plasma (FDP) stored refrigerated over 35 days. SAMPLE 6 units of canine LP and FFP-T from a commercial animal blood bank and 5 units each of 2 formulations of canine FDP. PROCEDURES Prothrombin time; activated partial thromboplastin time; activities of coagulation factors II, V, VII, VIII, IX, X, XI, and XII; and thromboelastographic parameters were determined for each product on days 0 (baseline), 3, 7, 14, 21, 28, and 35. For each day, a sample of each product was also submitted for aerobic bacterial culture. RESULTS Small changes in coagulation factor activities and mild increased time to initial clot formation in LP and FFP-T were noted over the 35-day storage period. Activities of factor VIII in FDP1 and factor XII in FDP2 were < 50% at baseline but varied throughout. Compared with FFP-T, time to initial clot formation was increased and clot strength was preserved or increased for the FDPs throughout the study. One FDP had decreased pH, compared with other products. No plasma product yielded bacterial growth. CONCLUSIONS AND CLINICAL RELEVANCE Liquid plasma and FFP-T would be reasonable to use when stored refrigerated for up to 35 days. Both FDP products showed variability in coagulation factor activities. Studies investigating the usefulness of these plasma products (FDPs) in dogs and the variable days of refrigerated storage (all products) are warranted. (Am J Vet Res 2020;81:964-972).
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Weiskopf RB, Glassberg E, Guinn NR, James MFM, Ness PM, Pusateri AE. The need for an artificial oxygen carrier for disasters and pandemics, including COVID-19. Transfusion 2020; 60:3039-3045. [PMID: 32978804 PMCID: PMC7537157 DOI: 10.1111/trf.16122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 01/29/2023]
Affiliation(s)
| | - Elon Glassberg
- The Israel Defense Force Medical Corps, Ramat Gan, Israel.,Departments of Surgery, Bar-Ilan University Faculty of Medicine, Safed, Israel, and The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Nicole R Guinn
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael F M James
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Paul M Ness
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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20
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Spinella PC, Thomas KA, Turnbull IR, Fuchs A, Bochicchio K, Schuerer D, Reese S, Coleoglou Centeno AA, Horn CB, Baty J, Shea SM, Meledeo MA, Pusateri AE, Levy JH, Cap AP, Bochicchio GV. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol 2020; 11:2085. [PMID: 33013880 PMCID: PMC7506112 DOI: 10.3389/fimmu.2020.02085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The hemostatic properties of tranexamic acid (TXA) are well described, but the immunological effects of TXA administration after traumatic injury have not been thoroughly examined. We hypothesized TXA would reduce monocyte activation in bleeding trauma patients with severe injury. Methods This was a single center, double-blinded, randomized controlled trial (RCT) comparing placebo to a 2 g or 4 g intravenous TXA bolus dose in trauma patients with severe injury. Fifty patients were randomized into each study group. The primary outcome was a reduction in monocyte activation as measured by human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes 72 h after TXA administration. Secondary outcomes included kinetic assessment of immune and hemostatic phenotypes within the 72 h window post-TXA administration. Results The trial occurred between March 2016 and September 2017, when data collection ended. 149 patients were analyzed (placebo, n = 50; 2 g TXA, n = 49; 4 g TXA, n = 50). The fold change in HLA-DR expression on monocytes [reported as median (Q1–Q3)] from pre-TXA to 72 h post-TXA was similar between placebo [0.61 (0.51–0.82)], 2 g TXA [0.57 (0.47–0.75)], and 4 g TXA [0.57 (0.44–0.89)] study groups (p = 0.82). Neutrophil CD62L expression was reduced in the 4 g TXA group [fold change: 0.73 (0.63–0.97)] compared to the placebo group [0.97 (0.78–1.10)] at 24 h post-TXA (p = 0.034). The fold decrease in plasma IL-6 was significantly less in the 4 g TXA group [1.36 (0.87–2.42)] compared to the placebo group [0.46 (0.19–1.69)] at 72 h post-TXA (p = 0.028). There were no differences in frequencies of myeloid or lymphoid populations or in classical complement activation at any of the study time points. Conclusion In trauma patients with severe injury, 4 g intravenous bolus dosing of TXA has minimal immunomodulatory effects with respect to leukocyte phenotypes and circulating cytokine levels. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02535949.
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Affiliation(s)
- Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Kimberly A Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Isaiah R Turnbull
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Anja Fuchs
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Kelly Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Douglas Schuerer
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Stacey Reese
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Adrian A Coleoglou Centeno
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher B Horn
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan M Shea
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - M Adam Meledeo
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Anthony E Pusateri
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, United States
| | - Andrew P Cap
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Grant V Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
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21
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Moore HB, Tessmer MT, Moore EE, Sperry JL, Cohen MJ, Chapman MP, Pusateri AE, Guyette FX, Brown JB, Neal MD, Zuckerbraun B, Sauaia A. Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock. J Trauma Acute Care Surg 2020; 88:588-596. [PMID: 32317575 PMCID: PMC7802822 DOI: 10.1097/ta.0000000000002614] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 02/07/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) support the use of prehospital plasma in traumatic hemorrhagic shock, especially in long transports. The citrate added to plasma binds with calcium, yet most prehospital trauma protocols have no guidelines for calcium replacement. We reviewed the experience of two recent prehospital plasma RCTs regarding admission ionized-calcium (i-Ca) blood levels and its impact on survival. We hypothesized that prehospital plasma is associated with hypocalcemia, which in turn is associated with lower survival. METHODS We studied patients enrolled in two institutions participating in prehospital plasma RCTs (control, standard of care; experimental, plasma), with i-Ca collected before calcium supplementation. Adults with traumatic hemorrhagic shock (systolic blood pressure ≤70 mm Hg or 71-90 mm Hg + heart rate ≥108 bpm) were eligible. We use generalized linear mixed models with random intercepts and Cox proportional hazards models with robust standard errors to account for clustered data by institution. Hypocalcemia was defined as i-Ca of 1.0 mmol/L or less. RESULTS Of 160 subjects (76% men), 48% received prehospital plasma (median age, 40 years [interquartile range, 28-53 years]) and 71% suffered blunt trauma (median Injury Severity Score [ISS], 22 [interquartile range, 17-34]). Prehospital plasma and control patients were similar regarding age, sex, ISS, blunt mechanism, and brain injury. Prehospital plasma recipients had significantly higher rates of hypocalcemia compared with controls (53% vs. 36%; adjusted relative risk, 1.48; 95% confidence interval [CI], 1.03-2.12; p = 0.03). Severe hypocalcemia was significantly associated with decreased survival (adjusted hazard ratio, 1.07; 95% CI, 1.02-1.13; p = 0.01) and massive transfusion (adjusted relative risk, 2.70; 95% CI, 1.13-6.46; p = 0.03), after adjustment for confounders (randomization group, age, ISS, and shock index). CONCLUSION Prehospital plasma in civilian trauma is associated with hypocalcemia, which in turn predicts lower survival and massive transfusion. These data underscore the need for explicit calcium supplementation guidelines in prehospital hemotherapy. LEVEL OF EVIDENCE Therapeutic, level II.
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Affiliation(s)
| | | | - Ernest E. Moore
- University of Colorado
- Ernest E. Moore Shock Trauma Center at Denver Health
| | | | - Mitchell J. Cohen
- University of Colorado
- Ernest E. Moore Shock Trauma Center at Denver Health
| | | | - Anthony E. Pusateri
- Combat Casualty Care Research Program, US Army Medical Research Materiel Command, Fort Detrick, Maryland
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22
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Pusateri AE, Moore EE, Moore HB, Le TD, Guyette FX, Chapman MP, Sauaia A, Ghasabyan A, Chandler J, McVaney K, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Sperry JL. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg 2020; 155:e195085. [PMID: 31851290 DOI: 10.1001/jamasurg.2019.5085] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance Both military and civilian clinical practice guidelines include early plasma transfusion to achieve a plasma to red cell ratio approaching 1:1 to 1:2. However, it was not known how early plasma should be given for optimal benefit. Two recent randomized clinical trials were published, with apparently contradictory results. The Prehospital Air Medical Plasma (PAMPer) clinical trial showed a nearly 30% reduction in mortality with plasma transfusion in the prehospital environment, while the Control of Major Bleeding After Trauma (COMBAT) clinical trial showed no survival improvement. Objective To facilitate a post hoc combined analysis of the COMBAT and PAMPer trials to examine questions that could not be answered by either clinical trial alone. We hypothesized that prehospital transport time influenced the effects of prehospital plasma on 28-day mortality. Design, Setting, and Participants A total of 626 patients in the 2 clinical trials were included. Patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 U of thawed plasma followed by standard care in the prehospital environment. Data analysis was performed between September 2018 and January 2019. Interventions Prehospital transfusion of 2 U of plasma compared with crystalloid-based resuscitation. Main Outcomes and Measures The main outcome was 28-day mortality. Results In this post hoc analysis of 626 patients (467 men [74.6%] and 159 women [25.4%]; median [interquartile range] age, 42 [27-57] years) who had trauma with hemorrhagic shock, a Cox regression analysis showed a significant overall survival benefit for plasma (hazard ratio [HR], 0.65; 95% CI, 0.47-0.90; P = .01) after adjustment for injury severity, age, and clinical trial cohort (COMBAT or PAMPer). A significant association with prehospital transport time was detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than 20 minutes (HR, 2.12; 95% CI, 1.05-4.30; P = .04), while increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40-1.51; P = .46). No serious adverse events were associated with prehospital plasma transfusion. Conclusions and Relevance These data suggest that prehospital plasma is associated with a survival benefit when transport times are longer than 20 minutes and that the benefit-risk ratio is favorable for use of prehospital plasma. Trial Registration ClinicalTrials.gov identifiers: NCT01838863 (COMBAT) and NCT01818427 (PAMPer).
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Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Ernest E Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Hunter B Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Tuan D Le
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Francis X Guyette
- Division of Emergency Medicine, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael P Chapman
- Department of Radiology, School of Medicine, University of Colorado Denver, Aurora
| | - Angela Sauaia
- Department of Health Systems, Management, and Policy, School of Public Health, University of Colorado Denver, Aurora
| | - Arsen Ghasabyan
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - James Chandler
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Kevin McVaney
- Department of Emergency Medicine, School of Medicine, University of Colorado Denver, Aurora
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jeffrey A Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A Phelan
- Department of Surgery, Parkland Memorial Hospital, University of Texas Southwestern, Dallas
| | | | - A Tyler Putnam
- Altoona Hospital, University of Pittsburgh Medical Center, Altoona, Pennsylvania
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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23
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Martini WZ, Holcomb JB, Yu YM, Wolf SE, Cancio LC, Pusateri AE, Dubick MA. Hypercoagulation and Hypermetabolism of Fibrinogen in Severely Burned Adults. J Burn Care Res 2020; 41:23-29. [PMID: 31504640 DOI: 10.1093/jbcr/irz147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study investigated changes in plasma fibrinogen metabolism and changes in coagulation in severely burned adults. Ten patients (27 ± 3 years; 91 ± 6 kg) with 51 ± 3% TBSA were consented and enrolled into an institutional review board-approved prospective study. On the study day, stable isotope infusion of 1-13C-phenylalanine and d5-phenylalanine was performed to quantify fibrinogen production and consumption. During the infusion, vital signs were recorded and blood samples were drawn every hour. Coagulation was measured by thromboelastograph (TEG). Ten normal healthy volunteers (37 ± 7 years; 74 ± 4 kg) were included as the control group. Burned adults had elevated heart rates (120 ± 2 vs 73 ± 5 [control] beats/minute), respiration rates (23 ± 2 vs 15 ± 1 breaths/minute), plasma glucose (127 ± 10 vs 89 ± 2 mg/dl), and fibrinogen levels (613 ± 35 vs 239 ± 17 mg/dl); and decreased albumin (1.3 ± 0.2 vs 3.7 ± 0.1 g/dl) and total protein (4.4 ± 0.2 vs 6.8 ± 0.1 g/dl, all P < .05). Fibrinogen breakdown was elevated in the burn group (2.3 ± 0.4 vs. 1.0 ± 0.3 µmol/kg/minute); and fibrinogen synthesis was further enhanced in the burn group (4.4 ± 0.7 vs 0.7 ± 0.2 µmol/kg/minute, both P < .05). Clotting speed (TEG-alpha) and clot strength (TEG-MA) were increased in the burn group (62 ± 4 vs 50 ± 4°, and 76 ± 2 vs 56 ± 2 mm, respectively, both P < .05). Fibrinolysis of TEG-LY60 was accelerated in the burn group (16 ± 6 vs 3 ± 1) and so was the increase in D-dimer level in the burn group (4.5 ± 0.4 vs 1.9 ± 0.3 mg/l, both P < .05). The hypercoagulable state postburn is in part a result of increased fibrinogen synthesis, over and above increased fibrinogen breakdown.
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Affiliation(s)
- Wenjun Z Martini
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| | - John B Holcomb
- University of Texas Health Science Center at Houston, Texas
| | - Yong-Ming Yu
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven E Wolf
- Shriner's Burn Hospital for Children, Galveston, Texas
| | | | | | - Michael A Dubick
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
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24
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Le TD, Gurney JM, Nnamani NS, Gross KR, Chung KK, Stockinger ZT, Nessen SC, Pusateri AE, Akers KS. A 12-Year Analysis of Nonbattle Injury Among US Service Members Deployed to Iraq and Afghanistan. JAMA Surg 2019; 153:800-807. [PMID: 29847675 DOI: 10.1001/jamasurg.2018.1166] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Nonbattle injury (NBI) among deployed US service members increases the burden on medical systems and results in high rates of attrition, affecting the available force. The possible causes and trends of NBI in the Iraq and Afghanistan wars have, to date, not been comprehensively described. Objectives To describe NBI among service members deployed to Iraq and Afghanistan, quantify absolute numbers of NBIs and proportion of NBIs within the Department of Defense Trauma Registry, and document the characteristics of this injury category. Design, Setting, and Participants In this retrospective cohort study, data from the Department of Defense Trauma Registry on 29 958 service members injured in Iraq and Afghanistan from January 1, 2003, through December 31, 2014, were obtained. Injury incidence, patterns, and severity were characterized by battle injury and NBI. Trends in NBI were modeled using time series analysis with autoregressive integrated moving average and the weighted moving average method. Statistical analysis was performed from January 1, 2003, to December 31, 2014. Main Outcomes and Measures Primary outcomes were proportion of NBIs and the changes in NBI over time. Results Among 29 958 casualties (battle injury and NBI) analyzed, 29 003 were in men and 955 were in women; the median age at injury was 24 years (interquartile range, 21-29 years). Nonbattle injury caused 34.1% of total casualties (n = 10 203) and 11.5% of all deaths (206 of 1788). Rates of NBI were higher among women than among men (63.2% [604 of 955] vs 33.1% [9599 of 29 003]; P < .001) and in Operation New Dawn (71.0% [298 of 420]) and Operation Iraqi Freedom (36.3% [6655 of 18 334]) compared with Operation Enduring Freedom (29.0% [3250 of 11 204]) (P < .001). A higher proportion of NBIs occurred in members of the Air Force (66.3% [539 of 810]) and Navy (48.3% [394 of 815]) than in members of the Army (34.7% [7680 of 22 154]) and Marine Corps (25.7% [1584 of 6169]) (P < .001). Leading mechanisms of NBI included falls (2178 [21.3%]), motor vehicle crashes (1921 [18.8%]), machinery or equipment accidents (1283 [12.6%]), blunt objects (1107 [10.8%]), gunshot wounds (728 [7.1%]), and sports (697 [6.8%]), causing predominantly blunt trauma (7080 [69.4%]). The trend in proportion of NBIs did not decrease over time, remaining at approximately 35% (by weighted moving average) after 2006 and approximately 39% by autoregressive integrated moving average. Assuming stable battlefield conditions, the autoregressive integrated moving average model estimated that the proportion of NBIs from 2015 to 2022 would be approximately 41.0% (95% CI, 37.8%-44.3%). Conclusions and Relevance In this study, approximately one-third of injuries during the Iraq and Afghanistan wars resulted from NBI, and the proportion of NBIs was steady for 12 years. Understanding the possible causes of NBI during military operations may be useful to target protective measures and safety interventions, thereby conserving fighting strength on the battlefield.
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Affiliation(s)
- Tuan D Le
- US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Jennifer M Gurney
- US Army Institute of Surgical Research, Fort Sam Houston, Texas.,Joint Trauma System, Fort Sam Houston, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Nina S Nnamani
- US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Kirby R Gross
- Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Army Trauma Training Detachment, Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Zsolt T Stockinger
- Joint Trauma System, Fort Sam Houston, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Shawn C Nessen
- US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | | | - Kevin S Akers
- US Army Institute of Surgical Research, Fort Sam Houston, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Pusateri AE, Butler FK, Shackelford SA, Sperry JL, Moore EE, Cap AP, Taylor AL, Homer MJ, Hoots WK, Weiskopf RB, Davis MR. The need for dried plasma - a national issue. Transfusion 2019; 59:1587-1592. [PMID: 30980738 DOI: 10.1111/trf.15261] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 01/10/2023]
Abstract
Recent studies have demonstrated that early transfusion of plasma or RBCs improves survival in patients with severe trauma and hemorrhagic shock. Time to initiate transfusion is the critical factor. It is essential that transfusion begin in the prehospital environment when transport times are longer than approximately 15 to 20 minutes. Unfortunately, logistic constraints severely limit the use of blood products in the prehospital setting, especially in military, remote civilian, and mass disaster circumstances, where the need can be most acute. US military requirements for logistically supportable blood products are projected to increase dramatically in future conflicts. Although dried plasma products have been available and safely used in a number of countries for over 20 years, there is no dried plasma product commercially available in the United States. A US Food and Drug Administration-approved dried plasma is urgently needed. Considering the US military, disaster preparedness, and remote civilian trauma perspectives, this is an urgent national health care issue.
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Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas
| | - Frank K Butler
- Committee on Tactical Combat Casualty Care, Joint Trauma System, Defense Center of Excellence for Trauma, JBSA, Fort Sam Houston
| | - Stacy A Shackelford
- Joint Trauma System, Defense Center of Excellence for Trauma, JBSA Fort Sam Houston, San Antonio, Texas
| | - Jason L Sperry
- Department of Surgery and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Andrew P Cap
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas
| | | | - Mary J Homer
- US Department of Health and Human Services (BARDA), Washington, DC
| | - W Keith Hoots
- National Institutes of Health (NHLBI), Bethesda, Maryland
| | | | - Michael R Davis
- US Army Medical Research and Materiel Command, Fort Detrick, Maryland
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26
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Bravo MC, Tejiram S, McLawhorn MM, Moffatt LT, Orfeo T, Jett-Tilton M, Pusateri AE, Shupp JW, Brummel-Ziedins KE. Utilizing Plasma Composition Data to Help Determine Procoagulant Dynamics in Patients with Thermal Injury: A Computational Assessment. Mil Med 2019; 184:392-399. [PMID: 30901410 DOI: 10.1093/milmed/usy397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/19/2018] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The development of methods that generate individualized assessments of the procoagulant potential of burn patients could improve their treatment. Beyond its role as an essential intermediate in the formation of thrombin, factor (F)Xa has systemic effects as an agonist to inflammatory processes. In this study, we use a computational model to study the FXa dynamics underlying tissue factor-initiated thrombin generation in a small cohort of burn patients. MATERIALS AND METHODS Plasma samples were collected upon admission (Hour 0) from nine subjects (five non-survivors) with major burn injuries and then at 48 hours. Coagulation factor concentrations (II, V, VII, VIII, IX, X, TFPI, antithrombin (AT), protein C (PC)) were measured and used in a computational model to generate time course profiles for thrombin (IIa), FXa, extrinsic tenase, intrinsic tenase and prothrombinase complexes upon a 5 pM tissue factor stimulus in the presence of 1 nM thrombomodulin. Parameters were extracted from the thrombin and FXa profiles (including max rate (MaxRIIa and MaxRFXa) and peak level (MaxLIIa and MaxLFXa)). Procoagulant potential was also evaluated by determining the concentration of the complexes at select times. Parameter values were compared between survivors and non-survivors in the burn cohort and between the burn cohort and a simulation based on the mean physiological (100%) concentration for all factor levels. RESULTS Burn patients differed at Hour 0 (p < 0.05) from 100% mean physiological levels for all coagulation factor levels except FV and FVII. The concentration of FX, FII, TFPI, AT and PC was lower; FIX and FVIII were increased. The composition differences resulted in all nine burn patients at Hour 0 displaying a procoagulant phenotype relative to 100% mean physiological simulation (MaxLIIa (306 ± 90 nM vs. 52 nM), MaxRIIa (2.9 ± 1.1 nM/s vs. 0.3 nM/s), respectively p < 0.001); MaxRFXa and MaxLFXa were also an order of magnitude greater than 100% mean physiological simulation (p < 0.001). When grouped by survival status and compared at the time of admission, non-survivors had lower PC levels (56 ± 18% vs. 82 ± 9%, p < 0.05), and faster MaxRFXa (29 ± 6 pM/s vs. 18 ± 6 pM/s, p < 0.05) than those that survived; similar trends were observed for all other procoagulant parameters. At 48 hours when comparing non-survivors to survivors, TFPI levels were higher (108 ± 18% vs. 59 ± 18%, p < 0.05), and MaxRIIa (1.5 ± 1.4 nM/s vs. 3.6 ± 0.7 nM/s, p < 0.05) and MaxRFXa (13 ± 12 pM/s vs. 35 ± 4 pM/s, p < 0.05) were lower; similar trends were observed with all other procoagulant parameters. Overall, between admission and 48 hours, procoagulant potential, as represented by MaxR and MaxL parameters for thrombin and FXa, in non-survivors decreased while in survivors they increased (p < 0.05). In patients that survived, there was a positive correlation between FX levels and MaxLFXa (r = 0.96) and reversed in mortality (r= -0.91). CONCLUSIONS Thrombin and FXa generation are increased in burn patients at admission compared to mean physiological simulations. Over the first 48 hours, burn survivors became more procoagulant while non-survivors became less procoagulant. Differences between survivors and non-survivors appear to be present in the underlying dynamics that contribute to FXa dynamics. Understanding how the individual specific balance of procoagulant and anticoagulant proteins contributes to thrombin and FXa generation could ultimately guide therapy and potentially reduce burn injury-related morbidity and mortality.
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Affiliation(s)
- Maria Cristina Bravo
- The Department of Biochemistry, College of Medicine, University of Vermont, 360 South Park Drive, Colchester, VT
| | - Shawn Tejiram
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Melissa M McLawhorn
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Lauren T Moffatt
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Thomas Orfeo
- The Department of Biochemistry, College of Medicine, University of Vermont, 360 South Park Drive, Colchester, VT
| | - Marti Jett-Tilton
- United States Army Center for Environmental Health Research, US Army Medical Command, 568 Doughten Drive, Fort Detrick, MD
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA - Fort Sam Houston, TX
| | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, 110 Irving Street, NW; Suite 3B-55, Washington, DC
| | - Kathleen E Brummel-Ziedins
- The Department of Biochemistry, College of Medicine, University of Vermont, 360 South Park Drive, Colchester, VT
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Pusateri AE, Homer MJ, Rasmussen TE, Kupferer KR, Hoots WK. The interagency strategic plan for research and development of blood products and related technologies for trauma care and emergency preparedness 2015-2020. Am J Disaster Med 2019; 13:181-194. [PMID: 30629273 DOI: 10.5055/ajdm.2018.0299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intensive blood use is expected to occur at levels, which will overwhelm blood supplies as they exist with current capabilities and technologies, both in civilian mass casualty events and military battlefield trauma. New technologies are needed for trauma care, and specifically to provide safer, more effective, and more logistically supportable blood products to treat patients with, or at risk of developing, acquired bleeding disorders resulting from trauma, acute radiation exposure, or other causes. Three of the primary agencies with major research and development programs related to blood products, the Biomedical Advanced Research and Development Authority (BARDA), the Department of Defense (DoD), and the National Heart, Lung, and Blood Institute are uniquely positioned to partner in addressing these issues, which have significant implications for each respective agency, as well as for the US population. Providing leadership, coordination, and oversight for the Food and Drug Administration's national and global health security, counterterrorism, and emerging threats portfolios, the US Food and Drug Administration Office of Counterterrorism and Emerging Threats serves in a critical advisory and facilitative role regarding development and availability of blood products. This plan is informed by the 2012 PHEMCE Strategy (US Department of Health and Human Services, 2012), the 2007 "Shaping the Future of Research" Strategic Plan for the National Heart, Lung, and Blood Institute, the 2011 BARDA Strategic Plan, the DoD Combat Casualty Care Research Program: Policy Review, the 2015 DoD Hemorrhage and Resuscitation Research and Development Strategic Plan, and more than 30 participants from other agencies who participated in planning.
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Affiliation(s)
- Anthony E Pusateri
- Chief Science Officer and Director of Research, US Army Institute of Surgical Research, Medical Research and Materiel Command, JBSA Fort Sam Houston, Texas
| | - Mary J Homer
- Chief, Radiological and Nuclear Countermeasures, Division of Chemical, Biological, Radiological, and Nuclear Countermeasures, Biomedical Advanced Research and Development Authority (BARDA), Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC
| | - Todd E Rasmussen
- Shumacker Professor of Surgery, Associate Dean for Clinical Research, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Kevin R Kupferer
- Research Scientist, US Army Institute of Surgical Research, Medical Research and Materiel Command, JBSA Fort Sam Houston, Texas
| | - W Keith Hoots
- Director, Division of Blood Diseases and Resources, National Institute of Health (NHLBI), Bethesda, Maryland
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Meledeo MA, Liu QP, Peltier GC, Carney RC, McIntosh CS, Taylor AS, Bynum JA, Pusateri AE, Cap AP. Spray‐dried plasma deficient in high‐molecular‐weight multimers of von Willebrand factor retains hemostatic properties. Transfusion 2018; 59:714-722. [DOI: 10.1111/trf.15038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Michael Adam Meledeo
- JBSA‐Fort Sam HoustonUnited States Army Institute of Surgical Research San Antonio Texas
| | | | - Grantham C. Peltier
- JBSA‐Fort Sam HoustonUnited States Army Institute of Surgical Research San Antonio Texas
| | | | - Colby S. McIntosh
- JBSA‐Fort Sam HoustonUnited States Army Institute of Surgical Research San Antonio Texas
| | - Ashley S. Taylor
- JBSA‐Fort Sam HoustonUnited States Army Institute of Surgical Research San Antonio Texas
| | - James A. Bynum
- JBSA‐Fort Sam HoustonUnited States Army Institute of Surgical Research San Antonio Texas
| | - Anthony E. Pusateri
- JBSA‐Fort Sam HoustonUnited States Army Institute of Surgical Research San Antonio Texas
| | - Andrew P. Cap
- JBSA‐Fort Sam HoustonUnited States Army Institute of Surgical Research San Antonio Texas
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Schauer SG, April MD, Naylor JF, Maddry JK, Arana AA, Dubick MA, Fisher AD, Cunningham CW, Pusateri AE. Prehospital Application of Hemostatic Agents in Iraq and Afghanistan. PREHOSP EMERG CARE 2018; 22:614-623. [DOI: 10.1080/10903127.2017.1423140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Pusateri AE, Ryan KL, Delgado AV, Martinez RS, Uscilowicz JM, Cortez DS, Martinowitz U. Effects of increasing doses of activated recombinant factor VII on haemostatic parameters in swine. Thromb Haemost 2017; 93:275-83. [PMID: 15711743 DOI: 10.1160/th04-03-0200] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 11/05/2022]
Abstract
SummaryThis study examined dose-response relationships between activated recombinant factorVII (rFVIIa) and (1) in vivo haemostasis and (2) in vitro measures of coagulation and platelet function. Anesthetized swine were used. Ear bleeding time (BT) was measured and blood was sampled following increasing doses of rFVIIa (0, 90, 180, 360 and 720 μg/kg; n = 6) or saline (n = 6). BT was not altered by rFVIIa. Prothrombin time (PT) using standard or pig-specific methods was decreased by rFVIIa. Activated clotting time (ACT) was decreased by rFVIIa. Thromboelastography using collagen (COLL) or pig thromboplastin (p-ThP) as agonist demonstrated shorter reaction times, shortened time to reach maximum velocity of clot formation, and increased α -angle in the presence of rFVIIa. rFVIIa dosing increased maximum velocity of clot formation when p-ThP was used to initiate the reaction but not when COLL was used. rFVIIa at the highest concentration increased maximum amplitude when COLL was used to initiate the reaction. Platelet aggregation was not altered by rFVIIa. Following completion of the dose escalation phase, a severe liver injury was produced. rFVIIa altered neither blood loss nor survival time following injury but improved mean arterial pressure. A small increase in systemic thrombin-antithrombin III complex occurred after administration of rFVIIa at doses of 180 μg/kg and above. However, there was no histological evidence of intravascular coagulation after rFVIIa administration. In summary, rFVIIa activity was detectable in vitro but did not change haemostasis in normal swine.
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Affiliation(s)
- Anthony E Pusateri
- U.S. Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Ft. Sam Houston, TX 78234-6315, USA.
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Gissel M, Brummel-Ziedins KE, Butenas S, Pusateri AE, Mann KG, Orfeo T. Effects of an acidic environment on coagulation dynamics. J Thromb Haemost 2016; 14:2001-2010. [PMID: 27431334 DOI: 10.1111/jth.13418] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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: 03/31/2016] [Accepted: 07/06/2016] [Indexed: 11/28/2022]
Abstract
Essentials Acidosis, an outcome of traumatic injury, has been linked to impaired procoagulant efficiency. In vitro model systems were used to assess coagulation dynamics at pH 7.4 and 7.0. Clot formation dynamics are slightly enhanced at pH 7.0 in blood ex vivo. Acidosis induced decreases in antithrombin efficacy offset impairments in procoagulant activity. SUMMARY Background Disruption of hydrogen ion homeostasis is a consequence of traumatic injury often associated with clinical coagulopathy. Mechanisms by which acidification of the blood leads to aberrant coagulation require further elucidation. Objective To examine the effects of acidified conditions on coagulation dynamics using in vitro models of increasing complexity. Methods Coagulation dynamics were assessed at pH 7.4 and 7.0 as follows: (i) tissue factor (TF)-initiated coagulation proteome mixtures (±factor [F]XI, ±fibrinogen/FXIII), with reaction progress monitored as thrombin generation or fibrin formation; (ii) enzyme/inhibitor reactions; and (iii) TF-dependent or independent clot dynamics in contact pathway-inhibited blood via viscoelastometry. Results Rate constants for antithrombin inhibition of FXa and thrombin were reduced by ~ 25-30% at pH 7.0. At pH 7.0 (+FXI), TF-initiated thrombin generation showed a 20% increase in maximum thrombin levels and diminished thrombin clearance rates. Viscoelastic analyses showed a 25% increase in clot time and a 25% reduction in maximum clot firmness (MCF). A similar MCF reduction was observed at pH 7.0 when fibrinogen/FXIII were reacted with thrombin. In contrast, in contact pathway-inhibited blood (n = 6) at pH 7.0, MCF values were elevated 6% (95% confidence interval [CI]: 1%-11%) in TF-initiated blood and 15% (95% CI: 1%- 29%) in the absence of TF. Clot times at pH 7.0 decreased 32% (95% CI: 15%-49%) in TF-initiated blood and 51% (95% CI: 35%-68%) in the absence of TF. Conclusions Despite reported decreased procoagulant catalysis at pH 7.0, clot formation dynamics are slightly enhanced in blood ex vivo and suppression of thrombin generation is not observed. A decrease in antithrombin reactivity is one potential mechanism contributing to these outcomes.
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Affiliation(s)
- M Gissel
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | | | - S Butenas
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | - A E Pusateri
- US Army Medical Research and Materiel Command, Fort Detrick, MD, USA
| | - K G Mann
- Haematologic Technologies, Essex Junction, VT, USA
| | - T Orfeo
- Department of Biochemistry, University of Vermont, Colchester, VT, USA.
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Abstract
Transfusion of plasma early after severe injury has been associated with improved survival. There are significant logistic factors that limit the ability to deliver plasma where needed in austere environments, such as the battlefield or during a significant civilian emergency. While some countries have access to more logistically supportable dried plasma, there is no such product approved for use in the United States. There is a clear need for a Food and Drug Administration (FDA)‐approved dried plasma for military and emergency‐preparedness uses, as well as for civilian use in remote or austere settings. The Department of Defense (DoD) and Biomedical Advanced Research and Development Authority are sponsoring development of three dried plasma products, incorporating different technologic approaches and business models. At the same time, the DoD is sponsoring prospective, randomized clinical studies on the prehospital use of plasma. These efforts are part of a coordinated program to provide a dried plasma for military and civilian applications and to produce additional information on plasma use so that, by the time we have an FDA‐approved dried plasma, we will better understand how to use it.
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Affiliation(s)
| | | | - Victor W Macdonald
- US Army Medical Materiel Development Activity, US Army Medical Materiel Command, Fort Detrick, Maryland
| | - Mary J Homer
- Biomedical Advanced Research and Development Authority, Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC
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Martini WZ, Rodriguez CM, Deguzman R, Guerra JB, Martin AK, Pusateri AE, Cap AP, Dubick MA. Dose Responses of Ibuprofen In Vitro on Platelet Aggregation and Coagulation in Human and Pig Blood Samples. Mil Med 2016; 181:111-6. [PMID: 27168560 DOI: 10.7205/milmed-d-15-00381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ibuprofen is commonly used by warfighters in the deployed environment. This study investigated its dose effects on in vitro coagulation in human and pig blood. METHODS Blood samples were collected from 6 normal volunteers and 6 healthy pigs and processed to make platelet-adjusted samples (100 × 10(3)/μL, common transfusion trigger in trauma). Ibuprofen was added to the samples at concentrations of 0 μg/mL (control), the concentration from the highest recommended oral dose (163 μg/mL, 1×), and 2×, 4×, 8×, 10×, 12×, 16×, and 20×. Platelet aggregation by Chrono-Log aggregometer and coagulation by rotational thrombelastogram (Rotem) were assessed at 15 minutes after the addition of ibuprofen. RESULTS A robust inhibition of ibuprofen on arachidonic acid-induced platelet aggregation was observed at all doses tested in human or pig blood. Collagen-stimulated platelet aggregation was inhibited starting at 1× in human blood and 4× in pig blood. Rotem measurements were similarly compromised in pig and human blood starting at 16×, except clot formation time was prolonged at 1× in human blood (all p < 0.05). CONCLUSION Ibuprofen inhibited platelet aggregation at recommended doses, and compromised coagulation at higher doses. Human blood was more sensitive to ibuprofen inhibition. Further effort is needed to investigate ibuprofen dose responses on coagulation in vivo.
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Affiliation(s)
- Wenjun Z Martini
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX 78234-6315
| | - Cassandra M Rodriguez
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX 78234-6315
| | - Rodolfo Deguzman
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX 78234-6315
| | - Jessica B Guerra
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX 78234-6315
| | | | - Anthony E Pusateri
- U.S. Army Medical Research and Materiel Command, Fort Detrick, 810 Schreider Street #100, Frederick, MD 21702
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX 78234-6315
| | - Michael A Dubick
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX 78234-6315
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Pusateri AE, Given MB, Schreiber MA, Spinella PC, Pati S, Kozar RA, Khan A, Dacorta JA, Kupferer KR, Prat N, Pidcoke HF, Macdonald VW, Malloy WW, Sailliol A, Cap AP. Dried plasma: state of the science and recent developments. Transfusion 2016; 56 Suppl 2:S128-39. [DOI: 10.1111/trf.13580] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/30/2016] [Accepted: 02/15/2016] [Indexed: 12/25/2022]
Affiliation(s)
| | | | | | | | - Shibani Pati
- Blood Systems Research Institute; San Francisco California
| | | | - Abdul Khan
- Velico Medical, Inc.; Beverly Massachusetts
| | | | | | - Nicolas Prat
- French Armed Forces Institute of Biomedical Research (IRBA) Bretigny-sur-Orge; France
| | | | - Victor W. Macdonald
- US Army Medical Materiel Development Activity; US Army Medical Research and Materiel Command; Fort Detrick Maryland
| | - Wilbur W. Malloy
- Congressionally Directed Medical Research Programs; US Army Medical Research and Materiel Command; Fort Detrick Maryland
| | - Anne Sailliol
- Centre de Transfusion Sanguine des Armées; Clamart CEDEX France
| | - Andrew P. Cap
- US Army Institute of Surgical Research; Fort Sam Houston Texas
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Vernon PJ, Schaub LJ, Dallelucca JJ, Pusateri AE, Sheppard FR. Rapid Detection of Neutrophil Oxidative Burst Capacity is Predictive of Whole Blood Cytokine Responses. PLoS One 2015; 10:e0146105. [PMID: 26716449 PMCID: PMC4696850 DOI: 10.1371/journal.pone.0146105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 12/14/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Maladaptive immune responses, particularly cytokine and chemokine-driven, are a significant contributor to the deleterious inflammation present in many types of injury and infection. Widely available applications to rapidly assess individual inflammatory capacity could permit identification of patients at risk for exacerbated immune responses and guide therapy. Here we evaluate neutrophil oxidative burst (NOX) capacity measured by plate reader to immuno-type Rhesus Macaques as an acute strategy to rapidly detect inflammatory capacity and predict maladaptive immune responses as assayed by cytokine array. METHODS Whole blood was collected from anesthetized Rhesus Macaques (n = 25) and analyzed for plasma cytokine secretion (23-plex Luminex assay) and NOX capacity. For cytokine secretion, paired samples were either unstimulated or ex-vivo lipopolysaccharide (LPS)-stimulated (100μg/mL/24h). NOX capacity was measured in dihydrorhodamine-123 loaded samples following phorbol 12-myristate 13-acetate (PMA)/ionomycin treatment. Pearson's test was utilized to correlate NOX capacity with cytokine secretion, p<0.05 considered significant. RESULTS LPS stimulation induced secretion of the inflammatory molecules G-CSF, IL-1β, IL-1RA, IL-6, IL-10, IL-12/23(p40), IL-18, MIP-1α, MIP-1β, and TNFα. Although values were variable, several cytokines correlated with NOX capacity, p-values≤0.0001. Specifically, IL-1β (r = 0.66), IL-6 (r = 0.74), the Th1-polarizing cytokine IL-12/23(p40) (r = 0.78), and TNFα (r = 0.76) were strongly associated with NOX. CONCLUSION NOX capacity correlated with Th1-polarizing cytokine secretion, indicating its ability to rapidly predict inflammatory responses. These data suggest that NOX capacity may quickly identify patients at risk for maladaptive immune responses and who may benefit from immuno-modulatory therapies. Future studies will assess the in-vivo predictive value of NOX in animal models of immune-mediated pathologies.
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Affiliation(s)
- Philip J. Vernon
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas, United States of America
| | - Leasha J. Schaub
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas, United States of America
| | | | - Anthony E. Pusateri
- US Army Medical Research and Materiel Command, Ft. Detrick, Maryland, United States of America
| | - Forest R. Sheppard
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas, United States of America
- * E-mail:
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White NJ, Contaifer D, Martin EJ, Newton JC, Mohammed BM, Bostic JL, Brophy GM, Spiess BD, Pusateri AE, Ward KR, Brophy DF. Early hemostatic responses to trauma identified with hierarchical clustering analysis. J Thromb Haemost 2015; 13:978-88. [PMID: 25816845 PMCID: PMC4452397 DOI: 10.1111/jth.12919] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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] [Received: 10/01/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Trauma-induced coagulopathy is a complex multifactorial hemostatic response that is poorly understood. OBJECTIVES To identify distinct hemostatic responses to trauma and identify key components of the hemostatic system that vary between responses. PATIENTS/METHODS A cross-sectional observational study of adult trauma patients at an urban level I trauma center emergency department was performed. Hierarchical clustering analysis was used to identify distinct clusters of similar subjects according to vital signs, injury/shock severity, and comprehensive assessment of coagulation, clot formation, platelet function, and thrombin generation. RESULTS Among 84 total trauma patients included in the model, three distinct trauma clusters were identified. Cluster 1 (N = 57) showed platelet activation, preserved peak thrombin generation, plasma coagulation dysfunction, a moderately decreased fibrinogen concentration and normal clot formation relative to healthy controls. Cluster 2 (N = 18) showed platelet activation, preserved peak thrombin generation, and a preserved fibrinogen concentration with normal clot formation. Cluster 3 (N = 9) was the most severely injured and shocked, and showed a strong inflammatory and bleeding phenotype. Platelet dysfunction, thrombin inhibition, plasma coagulation dysfunction and a decreased fibrinogen concentration were present in this cluster. Fibrinolytic activation was present in all clusters, but was particularly increased in cluster 3. Trauma clusters were most noticeably different in their relative fibrinogen concentration, peak thrombin generation, and platelet-induced clot contraction. CONCLUSIONS Hierarchical clustering analysis identified three distinct hemostatic responses to trauma. Further insights into the underlying hemostatic mechanisms responsible for these responses are needed.
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Affiliation(s)
- N J White
- Department of Medicine/Division of Emergency Medicine, University of Washington, and Puget Sound Blood Center Research Institute, Seattle, WA, USA
| | - D Contaifer
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - E J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - J C Newton
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - B M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - J L Bostic
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - G M Brophy
- Pharmacotherapy and Outcomes Science and Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - B D Spiess
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| | - A E Pusateri
- United States Army Medical Research and Materiel Command, Fort Detrick, MD, USA
| | - K R Ward
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - D F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
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Martini WZ, Deguzman R, Rodriguez CM, Guerra J, Martini AK, Pusateri AE, Dubick MA. Effect of Ibuprofen dose on platelet aggregation and coagulation in blood samples from pigs. Mil Med 2015; 180:80-5. [PMID: 25747637 DOI: 10.7205/milmed-d-14-00395] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ibuprofen is commonly used by Soldiers in the deployed environment. This study investigated its dose-effects on in vitro coagulation. METHODS Blood samples were collected from 4 normal healthy pigs and were processed to make platelet-adjusted (100×10(3)/μL) blood samples. Ibuprofen was added to the samples at doses of 0 μg/mL (control), recommended oral dose (163 μg/mL, 1×), 2×, 4×, 8×, 10×, 12×, 16×, and 20×. Arachidonic acid or collagen-stimulated platelet aggregation was assessed at 15 minutes after the addition of ibuprofen. Coagulation was assessed with measurements of prothrombin time (PT) and activated partial thromboplastin time (aPTT), and thrombelastography by Rotem. RESULTS A robust inhibition of ibuprofen on arachidonic acid-induced platelet aggregation was observed at all doses tested. Collagen-stimulated platelet aggregation was inhibited to 71%±5% and 10%±5% of the control values at ibuprofen doses of 4× and 20×, respectively (both p<0.05). No changes were observed in PT at any dose, but aPTT was prolonged at dose of 16× and 20×. Rotem measurements of coagulation time, clot formation time, maximum clot firmness, and A10 were compromised at dose 16× and 20× (all p<0.05). CONCLUSION Ibuprofen inhibited platelet aggregation at recommended doses, but did not compromise aPTT or coagulation profile until at 16 times the recommended doses and higher. Further effort is needed to clarify whether there are different dose-responses between human and pig blood samples in trauma situations.
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Affiliation(s)
- Wenjun Z Martini
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3698 Chambers Pass, Fort Sam Houston, TX 78234-6315
| | - Rodolfo Deguzman
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3698 Chambers Pass, Fort Sam Houston, TX 78234-6315
| | - Cassandra M Rodriguez
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3698 Chambers Pass, Fort Sam Houston, TX 78234-6315
| | - Jessica Guerra
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3698 Chambers Pass, Fort Sam Houston, TX 78234-6315
| | | | - Anthony E Pusateri
- U.S. Army Medical Research and Materiel Command, 722 Doughten Street/MCMR-RTC, Fort Detrick, MD 21702
| | - Michael A Dubick
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, 3698 Chambers Pass, Fort Sam Houston, TX 78234-6315
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Abstract
With the advent of remote damage control resuscitation and far-forward surgery, a renewed emphasis has been placed on examining a variety of pharmacologic adjuncts to controlling blood loss before definitive operative intervention. In this paper, the authors review the current state of the art for tranexamic acid (TXA) and its potential benefits to those patients who are in need of a massive transfusion. Specifically addressed are its biologic and pharmacologic properties, as well the results of a number of recent studies. The 2010 CRASH-2 trial randomized in excess of 20,000 patients and demonstrated a reduction in all-cause mortality from 16.0 to 14.5% and death due to bleeding from 5.7 to 4.9%. The 2012 Military Application of Tranexamic Acid in Trauma Emergency Resuscitation study provided a retrospective analysis of 896 wounded cared for at a military hospital in Afghanistan. This study demonstrated a 23.9%-17.4% reduction in all-cause mortality. Finally, they discuss the potential complications associated with TXA use as well as areas of future research, which are needed to solidify our knowledge of TXA and its potential beneficial effects on controlling bleeding.
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Affiliation(s)
- Joseph F Rappold
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
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Darlington DN, Kremenevskiy I, Pusateri AE, Scherer MR, Fedyk CG, Kheirabaldi BS, Delgado AV, Dubick MA. Effects of In vitro hemodilution, hypothermia and rFVIIa addition on coagulation in human blood. Int J Burns Trauma 2012; 2:42-50. [PMID: 22928166 PMCID: PMC3415967] [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] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 02/15/2012] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Coagulopathy can occur after hemorrhage, trauma and resuscitation, and has been associated with dilution of coagulation factors and hypothermia. Recombinant activated Factor VII (rFVIIa) has been used, often as a last resort, to improve hemostasis in trauma/hemorrhage patients with coagulopathy. The aim of this study was to further characterize the effects of rFVIIa on various coagulation parameters and the influence of temperature and hemodilution. METHODS WHOLE BLOOD FROM HEALTHY HUMAN VOLUNTEERS WAS INCUBATED IN A COMBINATION OF THREE CONDITIONS: undiluted or diluted 40% with either lactated Ringer's solution or Hextend, at 37°C or 34°C, and with and without rFVIIa (1.26 μg/ml, final concentration). Blood or plasma, as appropriate, was measured for coagulation by thrombin generation, thromboelastography (TEG), prothrombin Time (PT) and activated partial thromboplastin (aPTT). RESULTS Incubation of plasma at 34°C significantly elevated thrombin generation, and prolonged PT and aPTT. Dilution of blood or plasma with 40% Hextend, but not lactated Ringer's, had a significant effect on TEG parameters, and prolonged PT and aPTT. In control conditions (37°C, 0 dilution), the addition of rFVIIa to human plasma or whole blood led to a significant change in all TEG parameters, and Lagtime for thrombin generation, but not to PT or aPTT. CONCLUSION Theses data show that thrombin generation is affected by hypothermia, but not 40% dilution. TEG is affected by 40% dilution with Hextend, but not by hypothermia. PT and aPTT are significantly affected by both hypothermia and dilution. Recombinant FVIIa caused a greater change in thrombin generation at 34°C as compared to 37°C, and a greater change in PT at 40% dilution, suggesting that the effect of rFVIIa on coagulation is both temperature and dilution dependant.
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Skolnick BE, Shenouda M, Khutoryansky NM, Pusateri AE, Gabriel D, Carr ME. Reversal of Clopidogrel-Induced Bleeding with rFVIIa in Healthy Subjects. Anesth Analg 2011; 113:703-10. [DOI: 10.1213/ane.0b013e318228c690] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Holcomb JB, McManus JG, Kerr ST, Pusateri AE. Needle versus Tube Thoracostomy in a Swine Model of Traumatic Tension Hemopneumothorax. PREHOSP EMERG CARE 2009; 13:18-27. [DOI: 10.1080/10903120802290760] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Viuff D, Lauritzen B, Pusateri AE, Andersen S, Rojkjaer R, Johansson PI. Effect of haemodilution, acidosis, and hypothermia on the activity of recombinant factor VIIa (NovoSeven). Br J Anaesth 2008; 101:324-31. [PMID: 18565966 PMCID: PMC2517151 DOI: 10.1093/bja/aen175] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background A range of plasma volume expanders is used clinically, often in settings where haemostasis may already be impaired. The haemostatic agent, recombinant activated factor VII (rFVIIa, NovoSeven®), may be used to improve haemostasis but potential interactions with different volume expanders are poorly understood. Methods Clot formation was measured by thromboelastography (TEG) using blood from healthy volunteers. In vitro effects of rFVIIa with haemodilution, acidosis, and hypothermia were examined. Conditions were induced by dilution with NaCl (0.9%), lactated Ringer's solution, albumin 5%, or hydroxyethyl starch (HES) solutions [MW (molecular weight) 130–670 kDa]; by adjusting pH to 6.8 with 1 M HEPES (N-2-hydroxyethylpiperazine-N′-2-ethanesulphonic acid) buffer; or by reducing temperature to 32°C. We also studied the effect of low vs high MW HES (MW 200 vs 600 kDa) and rFVIIa on in vivo bleeding time (BT) in rabbits. Results Haemodilution progressively altered TEG parameters. rFVIIa improved TEG parameters in the presence of acidosis, hypothermia or 20% haemodilution (P<0.05). At 40% haemodilution, the rFVIIa effect was diminished particularly with high MW HES. In vivo, rFVIIa shortened the BT (P<0.05) with low but not high MW HES. Conclusions Efficacy of rFVIIa was affected by the degree of haemodilution and type of volume expander, but not by acidosis or hypothermia.
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Affiliation(s)
- D Viuff
- Hemostasis Pharmacology, Novo Nordisk A/S, Novo Nordisk Park, 2760 Måløv, Denmark.
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McMullin NR, Kauvar DS, Currier HM, Baskin TW, Pusateri AE, Holcomb JB. The Clinical and Laboratory Response to Recombinant Factor VIIa in Trauma and Surgical Patients with Acquired Coagulopathy. ACTA ACUST UNITED AC 2006; 63:246-51. [PMID: 16843774 DOI: 10.1016/j.cursur.2006.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [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: 11/18/2022]
Abstract
OBJECTIVE In bleeding patients who are coagulopathic, the clinical response to administration of recombinant factor VIIa (rFVIIa) relates to the changes in prothrombin time (PT). DESIGN Retrospective review of all surgical and trauma patients who were coagulopathic and received factor VIIa at the authors' institution over the past 27 months. SETTING Academic tertiary referral facility and level I trauma center. PARTICIPANTS Eighteen patients met inclusion criteria, 10 trauma and 8 surgical. Mean age 50 years (range, 17-84). RESULTS Overall mortality was 39%. All but 1 patient (17/18) had resolution of coagulopathic bleeding with rFVIIa, and all clinical responders (n = 17) (defined as clinical cessation of bleeding within 24 hours determined by either attending surgeon or chief resident progress note) had a decrease in PT to normal range. In contrast, the single clinical nonresponder had an insignificant PT decrease (19 to 18 seconds). Prothrombin time decreased from 20 +/- 4 seconds to 12 +/- 2 seconds, p < 0.05 (n = 17). International Normalized Ratio (INR) decreased from 1.59 to 0.86, p < 0.05 (n = 17). Fibrinogen before administration was 299.73 (range, 105-564) (n = 15). pH before administration was 7.25 (+/-0.18) (n = 10). Patient temperature was 98.64 (+/-2.06). Effect in partial thromboplastin time (PTT) was inconsistent (50 +/- 49 seconds to 34 +/- 6 seconds, p > 0.05). Transfusion requirements for red blood cells (14 to 3 units) and plasma (12 to 3 units) were significantly reduced after rFVIIa. There were no significant differences in percentage PT decrease between dose > or =100 mcg/kg vs <100 mcg/kg, surgical vs trauma patients, survivors vs nonsurvivors, and those with pretreatment platelet count > or =100 K vs <100 K. CONCLUSIONS The administration of rFVIIa caused a decrease in the PT in nearly all patients. There were an insufficient number of patients to support the use of PT as a clinical predictor of response; however, the data are suggestive of such utility. If the PT does not correct, then it is likely that there is a deficiency of other factors of the coagulation cascade.
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Affiliation(s)
- Neil R McMullin
- United States Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
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Abstract
BACKGROUND Coagulopathy is an important contributor to morbidity and mortality in trauma patients. Acidosis contributes to coagulopathy. Acidosis can be neutralized with intravascular bicarbonate, but it is unclear if the coagulation defect is rapidly reversed. The effects of acidosis and bicarbonate neutralization on coagulation function were investigated in vivo. METHODS Acidosis was induced in 12 pigs by infusing 0.2 mol/L HCl to pH 7.1. Pigs were then infused with either LR to maintain a pH of 7.1 (A-LR, n = 6) or 0.3 mol/L bicarbonate to a pH of 7.4 (A-Bi, n = 6). Blood samples were taken at baseline, 15 minutes after acidosis induction, and 15 minutes after bicarbonate neutralization. Coagulation function was assessed by prothrombin time (PT), partial thromboplastin time (PTT), thrombin generation, initial clot formation time (R), clotting rapidity (alpha), and clot strength (MA). RESULTS Compared with baseline values, acidosis reduced fibrinogen concentration to 66% +/- 2% in A-LR and to 71% +/- 3% in A-Bi, and decreased platelet counts to 49% +/- 4% in A-LR and to 53% +/- 4% in A-Bi. Thrombin generation decreased to 60% +/- 4% in A-LR and to 53% +/- 7% in A-Bi. Acidosis prolonged PT and PTT about 20% and decreased alpha and MA. After pH neutralization, fibrinogen and platelet levels remained depleted and no reversal of acidosis-induced changes in thrombin generation, PT, PTT, alpha, and MA were observed. CONCLUSION Acidosis impaired coagulation by depleting fibrinogen and platelets and by inhibiting clotting kinetics. The deficit associated with acidosis was not reversed with bicarbonate pH neutralization.
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Affiliation(s)
- Wenjun Z Martini
- US Army Institute of Surgical Research, Ft. Sam Houston, Texas, USA.
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Ryan KL, Cortez DS, Dick EJ, Pusateri AE. Efficacy of FDA-approved hemostatic drugs to improve survival and reduce bleeding in rat models of uncontrolled hemorrhage. Resuscitation 2006; 70:133-44. [PMID: 16757085 DOI: 10.1016/j.resuscitation.2005.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Revised: 11/06/2005] [Accepted: 11/06/2005] [Indexed: 10/24/2022]
Abstract
Several FDA-approved intravenous drugs are used to reduce surgical bleeding. This series of studies tested whether these drugs (aprotinin, desmopressin, tranexamic acid, epsilon-aminocaproic acid) could reduce bleeding due to traumatic injuries in two models of uncontrolled hemorrhage in rats. In the first phase of each study, a nonlethal tail bleeding model was used that incorporated limited fluid resuscitation (lactate Ringer's solution). Four doses of vehicle or the test substance were given successively with bleeding time and blood loss measured after each dose. In the second phase of each study, a lethal liver injury was produced by excising a section of the median lobe (approximately 0.8% of body weight) and an infusion of either vehicle or the test substance was immediately begun. This model included aggressive fluid resuscitation and a severe dilutional coagulopathy. Blood loss, survival time and mortality rate were recorded. Three studies were performed, testing each of the drugs singly and in combination. None of the drugs significantly reduced either bleeding time or blood loss in the tail bleeding model, nor were blood loss, survival time or mortality rate altered in the liver injury model. Taken together, these results suggest that these FDA-approved drugs, when used either singly or in combination, are not efficacious in these models of traumatic uncontrolled hemorrhage.
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Affiliation(s)
- Kathy L Ryan
- U.S. Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Ft. Sam Houston, TX 78234-6315, USA.
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Abstract
BACKGROUND Hemorrhage remains a leading cause of death in both civilian and military trauma patients. The HemCon chitosan-based hemostatic dressing is approved by the US Food and Drug Administration (FDA) for hemorrhage control. Animal data have shown the HemCon dressing to reduce hemorrhage and improve survival. The purpose of this article is to report preliminary results of the hemostatic efficacy of the HemCon dressing used in the prehospital setting on combat casualties. METHODS A request for case information on use of HemCon dressings in Operation Iraqi Freedom and Operation Enduring Freedom was sent to deployed Special Forces combat medics, physicians, and physician assistants. RESULTS Sixty-eight uses of the HemCon dressing were reported and reviewed by two US Army physicians. Four of the 68 cases were determined duplicative resulting in a total of 64 combat uses. Dressings were utilized externally on the chest, groin, buttock, and abdomen in 25 cases; on extremities in 35 cases; and on neck or facial wounds in 4 cases. In 66% of cases, dressings were utilized following gauze failure and were 100% successful. In 62 (97%) of the cases, the use of the HemCon dressing resulted in cessation of bleeding or improvement in hemostasis. There were two reported dressing failures that occurred with blind application of bandages up into large cavitational injuries. Dressings were reported to be most useful on areas where tourniquets could not be applied to control bleeding. The dressings were reported to be most difficult to use in extremity injuries where they could not be placed easily onto or into the wounds. No complications or adverse events were reported. CONCLUSION This report on the field use of the HemCon dressing by medics suggests that it is a useful hemostatic dressing for prehospital combat casualties and supports further study to confirm efficacy.
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Affiliation(s)
- Ian Wedmore
- Madigan Army Medical Center, Fort Lewis, Washington, USA
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Abstract
A number of new hemostatic products have been developed recently for use in trauma settings of severe uncontrolled bleeding. Currently, the literature on these products is controversial, with efficacy demonstrated under some circumstances but not others. In this review, we analyze the current literature pertaining to four of the most promising products (dry fibrin sealant dressing, Rapid Deployment Hemostat, HemCon chitosan dressing, and QuikClot) that have been suggested for use in combat casualty care applications. In particular, this analysis takes into account the characteristics of the animal models used for efficacy testing of these products, the desired characteristics of hemostatic dressings, and specific safety considerations. Animal models ranged from those featuring low-pressure/low-flow bleeding to those featuring high-pressure/high-flow bleeding. When data are viewed in the context of the specific characteristics of the differing animal models used, seemingly disparate experimental results related to efficacy and safety become quite complementary and lead to recommendations for the use of different products in different injury scenarios. Mission and training requirements will dictate the use of these products by military and civilian prehospital care providers.
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Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, Fort Sam Houston, Texas 78234, and the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
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Martini WZ, Chinkes DL, Pusateri AE, Holcomb JB, Yu YM, Zhang XJ, Wolfe RR. Acute changes in fibrinogen metabolism and coagulation after hemorrhage in pigs. Am J Physiol Endocrinol Metab 2005; 289:E930-4. [PMID: 15956050 DOI: 10.1152/ajpendo.00137.2005] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hemorrhagic coagulopathy is involved in the morbidity and mortality of trauma patients. Nonetheless, many aspects of the mechanisms underlying this disorder are poorly understood. We have therefore investigated changes in fibrinogen metabolism and coagulation function after a moderate hemorrhagic shock, using a new stable isotope approach. Twelve pigs were randomly divided into the control (C) and hemorrhage (H) groups. Hemorrhage was induced by bleeding 35% total blood volume over a 30-min period. A primed constant infusion of [1-(13)C]phenylalanine (Phe), d5-phenylalanine, and alpha-[1-(13)C]-ketoisocaproate (KIC) was given to quantify fibrinogen synthesis and breakdown, together with measurements of circulating liver enzyme activities and coagulation function. Mean arterial pressure was decreased by hemorrhage from 89 +/- 4 mmHg in C to 47 +/- 4 mmHg in H (P < 0.05), followed by a rebound to 68 +/- 5 mmHg afterward. Fibrinogen fractional synthesis rate increased from 2.7 +/- 0.2%/h in C to 4.2 +/- 0.4%/h in H by Phe (P < 0.05) and from 3.1 +/- 0.4%/h in C to 4.4 +/- 0.5%/h in H by KIC (P < 0.05). Fibrinogen fractional breakdown rate increased from 3.6 +/- 1.0%/h in C to 12.9 +/- 1.8%/h in H (P < 0.05). The absolute breakdown rate accelerated from 3.0 +/- 0.4 mg x kg(-1) x h(-1) in C to 5.4 +/- 0.6 mg x kg(-1) x h(-1) in H (P < 0.05), but the absolute synthesis rate remained unchanged. These metabolic changes were accompanied by a reduction in blood clotting time to 92.7 +/- 1.6% of the baseline value by hemorrhage (P < 0.05). No changes were found in liver enzyme activities. We conclude that the observed changes in coagulation after hemorrhagic shock are mechanistically related to the acute acceleration of fibrinogen degradation.
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Affiliation(s)
- Wenjun Z Martini
- The US Army Institute of Surgical Research, 3400 Rawley E. Chambers Ave., Ft. Sam Houston, TX 78234, USA
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Abstract
As interest in the use of activated recombinant factor VII (rFVIIa) in trauma grows, questions arise regarding how best to monitor rFVIIa therapy and when rFVIIa may be expected to improve hemostasis. Knowledge of the mechanisms of action may be combined with available data on laboratory monitoring and efficacy in various coagulopathic states in coming to clinically relevant conclusions. This review addresses the physiology of hemostasis, placing emphasis on how rFVIIa influences the process by both tissue factor dependent and tissue factor independent mechanisms. This is extended to a mechanistic consideration of how rFVIIa may function under acidotic, hypothermic, and hemodilutional and/or consumptive conditions of trauma related coagulopathy. When these considerations are viewed alongside the available clinical data, it becomes apparent that rFVIIa has potential to improve hemostasis during trauma coagulopathy, within limitations. Common laboratory procedures are discussed with reference to mechanisms of action of rFVIIa and the available clinical data. Although there is no single assay that can predict rFVIIa efficacy in trauma, the prothrombin time (PT) is recommended as a minimum. Although a shortened PT does not predict success, correction of PT into the normal range may be a better indicator. A nonresponding PT appears to indicate that rFVIIa alone will not lead to hemostasis, and that additional blood products and other measures must be applied. Once the patient is more stable, PT and thromboelastography are recommended.
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Abstract
OBJECTIVE To provide a physiological assessment of the U.S. Army one-handed tourniquet (OHT). METHODS An OHT was self-applied by 26 subjects, to maximal tolerable tightness, to the proximal arm or thigh under different conditions and positions, and the presence of blood flow was assessed using Doppler ultrasonography or occlusion plethysmography. RESULTS Doppler sound was eliminated at the radial artery for all subjects with OHT application but was not stopped at the popliteal or dorsalis pedis artery for any subjects. The OHT reduced forearm blood flow by 79% but decreased leg blood flow by only approximately 50%, regardless of condition and position of application to the thigh. CONCLUSIONS The OHT appears to effectively minimize blood flow in the arm but not in the lower extremities, and clinical assessment of blood flow disappearance by Doppler ultrasonography may underestimate the magnitude of actual blood flow to the limb.
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Affiliation(s)
- Joseph C Wenke
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234-6315, USA
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