Evaluating Thera-101 as a Low-Volume Resuscitation Fluid in a Model of Polytrauma.

Traumatic brain injury (TBI) and hemorrhage remain challenging to treat in austere conditions. Developing a therapeutic to mitigate the associated pathophysiology is critical to meet this treatment gap, especially as these injuries and associated high mortality are possibly preventable. Here, Thera-101 (T-101) was evaluated as low-volume resuscitative fluid in a rat model of TBI and hemorrhage. The therapeutic, T-101, is uniquely situated as a TBI and hemorrhage intervention. It contains a cocktail of proteins and microvesicles from the secretome of adipose-derived mesenchymal stromal cells that can act on repair and regenerative mechanisms associated with poly-trauma. T-101 efficacy was determined at 4, 24, 48, and 72 h post-injury by evaluating blood chemistry, inflammatory chemo/cytokines, histology, and diffusion tensor imaging. Blood chemistry indicated that T-101 reduced the markers of liver damage to Sham levels while the levels remained elevated with the control (saline) resuscitative fluid. Histology supports the potential protective effects of T-101 on the kidneys. Diffusion tensor imaging showed that the injury caused the most damage to the corpus callosum and the fimbria. Immunohistochemistry suggests that T-101 may mitigate astrocyte activation at 72 h. Together, these data suggest that T-101 may serve as a potential field deployable low-volume resuscitation therapeutic.

Comparative evaluation of mesenchymal stromal cell growth and osteogenic differentiation on a shape memory polymer scaffold.

Trauma-induced, critical-size bone defects pose a clinical challenge to heal. Albeit autografts are the standard-of-care, they are limited by their inability to be shaped to various defect geometries and often incur donor site complications. Herein, the combination of a "self-fitting" shape memory polymer (SMP) scaffold and seeded mesenchymal stromal cells (MSCs) was investigated as an alternative. The porous SMP scaffold, prepared from poly(ε-caprolactone) diacrylate (PCL-DA) and coated with polydopamine, provided conformal shaping and cell adhesion. MSCs from five tissues, amniotic (AMSCs), chorionic tissue (CHSCs), umbilical cord (UCSCs), adipose (ADSCs), and bone marrow (BMSCs) were evaluated for viability, density, and osteogenic differentiation on the SMP scaffold. BMSCs exhibited the fastest increase in cell density by day 3, but after day 10, CHSCs, UCSCs, and ADSCs approached similar cell density. BMSCs also showed the greatest calcification among the cell types, followed closely by ADSCs, CHSCs and AMSCs. Alkaline phosphatase (ALP) activity peaked at day 7 for AMSCs, UCSCs, ADSCs and BMSCs, and at day 14 for CHSCs, which had the greatest overall ALP activity. Of all the cell types, only scaffolds cultured with ADSCs in osteogenic media had increased hardness and local modulus as compared to blank scaffolds after 21 days of cell culture and osteogenic differentiation. Overall, ADSCs performed most favorably on the SMP scaffold. The SMP scaffold was able to support key cellular behaviors of MSCs and could potentially be a viable, regenerative alternative to autograft.

Combat wounds in operation Iraqi Freedom and operation Enduring Freedom.

BACKGROUND: There have been no large cohort reports detailing the wounding patterns and mechanisms in the current conflicts in Iraq and Afghanistan. METHODS: The Joint Theater Trauma Registry was queried for all US service members receiving treatment for wounds (International Classification of Diseases-9th Rev. codes 800-960) sustained in Operation Iraqi Freedom and Operation Enduring Freedom from October 2001 through January 2005. Returned-to-duty and nonbattle injuries were excluded from final analysis. RESULTS: This query resulted in 3,102 casualties, of which 31% were classified as nonbattle injuries and 18% were returned-to-duty within 72 hours. A total of 1,566 combatants sustained 6,609 combat wounds. The locations of these wounds were as follows: head (8%), eyes (6%), ears (3%), face (10%), neck (3%), thorax (6%), abdomen (11%), and extremity (54%). The proportion of head and neck wounds is higher (p < 0.0001) than the proportion experienced in World War II, Korea, and Vietnam wars (16%-21%). The proportion of thoracic wounds is a decrease (p < 0.0001) from World War II and Vietnam (13%). The proportion of gunshot wounds was 18%, whereas the proportion sustained from explosions was 78%. CONCLUSIONS: The wounding patterns currently seen in Iraq and Afghanistan resemble the patterns from previous conflicts, with some notable exceptions: a greater proportion of head and neck wounds, and a lower proportion of thoracic wounds. An explosive mechanism accounted for 78% of injuries, which is the highest proportion seen in any large-scale conflict.

Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom.

OBJECTIVES: Extremity wounds and fractures traditionally comprise the majority of traumatic injuries in US armed conflicts. Little has been published regarding the extremity wounding patterns and fracture distribution in the current conflicts in Iraq and Afghanistan. The intent of this study was to describe the distribution of extremity fractures during this current conflict. DESIGN: Descriptive epidemiologic study. METHODS: The Joint Theater Trauma Registry was queried for all US service members receiving treatment for wounds (ICD-9 codes 800-960) sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) from October 2001 through January 2005. Returned-to-duty and nonbattle injuries were excluded. Wounds were classified according to region and type. Extremity wounds were analyzed in detail and compared to published results from previous conflicts. RESULTS: A total of 1281 soldiers sustained 3575 extremity combat wounds. Fifty-three percent of these were penetrating soft-tissue wounds and 26% were fractures. Of the 915 fractures, 758 (82%) were open fractures. The 915 fractures were evenly distributed between the upper (461, 50%) and lower extremities (454, 50%). The most common fracture in the upper extremity was in the hand (36%) and in the lower extremity was the tibia and fibula (48%). Explosive munitions accounted for 75% of the mechanisms of injury. CONCLUSIONS: The burden of wounds sustained in OIF/OEF is extremity injuries, specifically soft-tissue wounds and fractures. These results are similar to the reported casualties from previous wars.

Effect of recombinant FVIIa in hypothermic, coagulopathic pigs with liver injuries.

BACKGROUND: Previous experiments with diverse pig models to evaluate the ability of rFVIIa to reduce hemorrhage have provided divergent results. The current study was conducted to address concerns related to previous work by using larger sample sizes, and an extended observational period of 4 hours post-injury. The objectives were to evaluate further the hemostatic efficacy and safety of rFVIIa administration after traumatic, uncontrolled hemorrhage. METHODS: Anesthetized, splenectomized pigs (36.6 +/- 0.3 kg; n = 18/group) underwent an approximately 50% isovolemic blood exchange with 33 degrees C 6% hetastarch, and body temperature was adjusted to 32.5 +/- 0.5 degrees C. Subsequently, a Grade V liver injury was inflicted. After 30 seconds, either vehicle or treatment (180 microg/kg or 720 microg/kg rFVIIa) was administered intravenously as a bolus. Concomitantly, laparotomy pads were packed around the liver. Resuscitation with 33 degrees C lactated Ringer's solution (260 mL/min) was initiated and pigs were monitored for 4 hour post-injury or until death. Tissues were collected and examined histologically to assess the presence of disseminated intravascular coagulation (DIC). RESULTS: Liver injuries were comparable among all groups (p = 0.89). Measures associated with in vitro coagulation (prothrombin time, activated partial thromboplastin time, thromboelastographic split-point and R times) were enhanced by rFVIIa administration (p < 0.05). However, neither percent survival (p = 0.82), survival time (p = 0.56), nor blood loss (p = 0.63) were affected by treatment. DIC was not evident in lung or kidney tissue. CONCLUSIONS: These data indicate an inability of rFVIIa at these doses to reduce blood loss, or to increase survival time or percent survival in this pig model. Absence of DIC provides evidence for safe use of rFVIIa under conditions specific to this study.

Evaluation of commercially available fluid-warming devices for use in forward surgical and combat areas.

The fluid-warming capabilities of four individual fluid warmers, i.e., Level 1, FMS 2000, Thermal Angel, and Ranger, were compared to evaluate their potential for medical use in forward military echelons of care. Lactated Ringer's solution (LR) and Hextend at room temperature (20 degrees C) or refrigerated temperature (4-7 degrees C) and packed red blood cells at 4 degrees C to 7 degrees C were used with each warmer at two different flow rates. The FMS 2000 consistently warmed all fluids to approximately 37 degrees C, regardless of the starting temperature or flow rate. The Level 1 and Ranger also efficiently warmed all fluids except cold LR to approximately 37 degrees C. The Thermal Angel generally warmed room temperature fluid, cold Hextend, and packed red blood cells to at least 33 degrees C to 34 degrees C but could not warm cold LR. The clinical standard is to have fluids warmed to 32 degrees C at a minimum and more preferably to 34 degrees C to 35 degrees C. Of the fluid warmers tested, only the Thermal Angel failed to achieve such a temperature in warming cold LR. Data from the present study suggest the Ranger and FMS 2000 to be operationally adaptable to at least echelons 1 and 2, respectively, whereas far-forward use of the Thermal Angel has limitations.

Superior mesenteric artery occlusion models shock-induced gut ischemia-reperfusion.

INTRODUCTION: Superior mesenteric artery occlusion (SMAO) is a simple and reproducible model of shock-induced gut ischemia/reperfusion, but some argue that it is not clinically relevant. The purpose of the current study was to compare SMAO to a standard model of controlled hemorrhage (CH) and uncontrolled hemorrhage (UH). METHODS: Rats had femoral lines and a jejunal mucosal laser Doppler placed followed by SMAO (60 min of ischemia, no resuscitation), controlled hemorrhage (40 mm Hg for 60 min, 2:1 resuscitation shed blood and lactated Ringers), or uncontrolled hemorrhage (liver injury, 3:1 resuscitation with lactated Ringers). Base deficit, lactate, and jejunal mucosal flow (as a percentage of baseline) were recorded during ischemia and for 120 min after reperfusion. Jejunal tissue was harvested for morphological evaluation. Comparison among groups was by analysis of variance (ANOVA), and significance was set at P < 0.05. RESULTS: Mucosal blood flow was similar among groups at the onset of reperfusion (CH, 16.9 +/- 5.0% versus UH, 10.9 +/- 3.1% versus SMAO, 13.9 +/- 6.2%) and during the initial period of reperfusion. By 120 min, however, flow in CH (75.4 +/- 2.5%) was significantly higher that in either UH (36.4 +/- 13.1%) or SMAO (31.7 +/- 8.4%). Histological injury was less with CH, while base deficit was significantly higher in CH at the onset of reperfusion (-24 +/- 2 versus UH, -10 +/- 3 and SMAO, -6 +/- 3 mM/L) but comparable by the end (CH, -17 +/- 4 versus UH, -16 +/- 3 and SMAO, -17 +/- 2 mM/L). CONCLUSIONS: SMAO is a clinically relevant model of shock-induced gut ischemia/reperfusion.

The effect of recombinant factor VIIa on noncoagulopathic pigs with grade V liver injuries.

BACKGROUND: Recombinant Factor VIIa (rFVIIa) has been used to decrease bleeding in a number of settings, including hemophilia, liver transplantation, intractable bleeding, and cirrhosis. It has also been shown to reduce bleeding in coagulopathic pigs with Grade V liver injuries when used as an adjunct to packing. This study was performed to determine if rFVIIa would reduce blood loss after a Grade V liver injury in noncoagulopathic pigs when used as sole therapy. STUDY DESIGN: Thirty normothermic animals were randomized to receive either 150 microg/kg of rFVIIa or normal saline intravenously. After laparotomy and splenectomy, a standardized Grade V liver injury was made with a liver clamp. Thirty seconds after injury, blinded therapy was given. Blood loss was measured 15 minutes after injury and the abdomen was closed. Animals were resuscitated to their baseline blood pressure and the study was continued for 2 hours. Serial coagulation parameters were obtained. Following the study period, blood loss was measured and an autopsy was performed. Grossly normal areas of lung were examined for evidence of intravascular thrombosis. RESULTS: Mean Factor VII:C levels increased 155-fold in the treatment group after infusion of rFVIIa. The mean prothrombin time in the treatment group decreased from 9.8 +/- 0.4 seconds to 7.3 +/- 0.2 seconds and remained significantly different from the control group throughout the study (p < 0.01). There were no differences in other coagulation parameters. Mean initial blood loss was 822 +/- 266 mL in the treatment group and 768 +/- 215 mL in the control group (p = 0.6). Rebleeding blood volume was 397 +/- 191 mL in the treatment group and 437 +/- 274 mL (p = 0.6) in the control group. Lung histology revealed no evidence of abnormal microvascular thrombosis. CONCLUSIONS: rFVIIa does not reduce blood loss after Grade V liver injury when it is used as sole therapy in warm noncoagulopathic pigs.

The effect of recombinant factor VIIa on coagulopathic pigs with grade V liver injuries.

BACKGROUND: Recombinant factor VIIa (rFVIIa) has been used to decrease bleeding in a number of settings including hemophilia, liver transplantation, intractable bleeding, and cirrhosis. Experience in the trauma setting is limited. This study was performed to determine whether rFVIIa would reduce bleeding after a grade V liver injury in hypothermic, dilutionally coagulopathic pigs when used as an adjunct to abdominal packing and to determine whether increasing the dose of the drug increased its hemostatic efficacy. METHODS: Thirty animals were randomized to receive 180 microg/kg of rFVIIa, 720 microg/kg of rFVIIa, or vehicle buffer control. After laparotomy and splenectomy, animals underwent a 60% blood volume isovolemic exchange transfusion with 5% human albumin. The animals' temperature was maintained at 33 degrees C and a standardized grade V liver injury was made with a liver clamp. Thirty seconds after injury, the abdomen was packed with laparotomy sponges, resuscitation was initiated, and blinded therapy was given. Animals were resuscitated to their baseline mean arterial pressure and the study was continued for 2 hours. Serial coagulation parameters were measured at the temperature they were drawn. After the study period, surviving animals were killed, posttreatment blood loss was measured, and an autopsy was performed. RESULTS: Ten animals were randomized to each group. After administration of study drug, factor VII clotting activity (FVII:C) was higher in the 720 microg/kg group than in the 180 microg/kg group (p < 0.01). FVII:C was higher in both treatment groups than in the control group (p < 0.01). The mean prothrombin time was shorter in the treatment groups than in the control group (p < 0.05). Mean arterial pressure was lower in the control group than in the treatment groups throughout the study (p < 0.01). Mean blood loss was less in the treatment groups than in the control group (p = 0.03). Mortality was not different between groups. There were no differences between the groups that received rFVIIa in any measured parameters except for FVII:C. Liver injuries were similar between groups and there was no evidence of microthrombosis on lung histology. CONCLUSION: rFVIIa reduces blood loss in hypothermic, dilutionally coagulopathic pigs with grade V injuries when used as an adjunct to packing. Increasing the dose does not enhance the hemostatic effect.