Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 6 de 6
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Artigo em Inglês | MEDLINE | ID: mdl-32068720

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is recommended in adults with a non-compressible torso hemorrhage with occlusion times of less than 60 minutes. The tolerable duration in children is unknown. We used a pediatric swine controlled hemorrhage model to evaluate the physiologic effects of 30 and 60 minutes of REBOA. METHODS: Pediatric swine weighing 20-30kg underwent a splenectomy and a controlled 60% total blood volume hemorrhage over 30 minutes, followed by either Zone 1 REBOA for 30 minutes (30R) or 60 minutes (60R). Swine were then resuscitated with shed blood and received critical care for 240 minutes. RESULTS: During critical care, the 30R group's (n=3) pH, bicarbonate, base excess and lactate were no different than baseline, while at the end of critical care, these variables continued to differ from baseline in the 60R group (n=5) and were worsening (7.4 vs 7.2, p<0.001, 30.4 vs 18.4mmol/L, p<0.0001, 5.6 vs -8.5mmol/L, p<0.0001, 2.4 vs 5.7mmol/L, p<0.001, respectively). Compared to baseline, end creatinine and creatinine kinase were elevated in 60R swine (1.0 vs 1.7mg/dL, p<0.01 and 335.4 vs 961.0U/L, p<0.001, respectively), but not 30R swine (0.9 vs 1.2 mg/dL, p=0.06 and 423.7 vs 769.5U/L, p=0.15, respectively). There was no difference in survival time between the 30R and 60R pediatric swine, p=0.99. CONCLUSION: The physiologic effects of 30 minutes of Zone 1 REBOA in pediatric swine mostly resolved during the subsequent 4 hours of critical care, whereas the effects of 60 minutes of REBOA persisted and worsened after 4 hours of critical care. Sixty minutes of Zone 1 REBOA may create an irreversible physiologic insult in a pediatric population. LEVEL OF EVIDENCE: Not applicable, translational animal scienceOriginal article.

2.
J Trauma Acute Care Surg ; 88(2): 298-304, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31996655

RESUMO

BACKGROUND: Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) and intermittent REBOA (iREBOA) are techniques to extend the therapeutic duration of REBOA by balloon titration for distal flow or cyclical balloon inflation/deflation to allow transient distal flow, respectively. We hypothesized that manually titrated pREBOA would reduce blood losses and ischemic burden when compared with iREBOA. METHODS: Following 20% blood volume controlled hemorrhage, 10 anesthetized pigs underwent uncontrolled hemorrhage from the right iliac artery and vein. Once in hemorrhagic shock, animals underwent 15 minutes of complete zone 1 REBOA followed by 75 minutes of either pREBOA or iREBOA (n = 5/group). After 90 minutes, definitive hemorrhage control was obtained, animals were resuscitated with the remaining collected blood, and then received 2 hours of critical care. RESULTS: There were no differences in mortality. Animals randomized to iREBOA spent a larger portion of the time at full occlusion when compared with pREBOA (median, 70 minutes; interquartile range [IQR], 70-80 vs. median, 20 minutes; IQR, 20-40, respectively; p = 0.008). While the average blood pressure during the intervention period was equivalent between groups, this was offset by large fluctuations in blood pressure and significantly more rescue occlusions for hypotension with iREBOA. Despite lower maximum aortic flow rates, the pREBOA group tolerated a greater total amount of distal aortic flow during the intervention period (median, 20.9 L; IQR, 20.1-23.0 vs. median, 9.8 L; IQR, 6.8-10.3; p = 0.03) with equivalent abdominal blood losses. Final plasma lactate and creatinine concentrations were equivalent, although iREBOA animals had increased duodenal edema on histology. CONCLUSION: Compared with iREBOA, pREBOA reduced the time spent at full occlusion and the number of precipitous drops in proximal mean arterial pressure while delivering more distal aortic flow but not increasing total blood loss in this highly lethal injury model. Neither technique demonstrated a survival benefit. Further refinement of these techniques is necessary before clinical guidelines are issued.


Assuntos
Oclusão com Balão/métodos , Procedimentos Endovasculares/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Animais , Aorta/cirurgia , Oclusão com Balão/efeitos adversos , Oclusão com Balão/instrumentação , Modelos Animais de Doenças , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Análise de Sobrevida , Sus scrofa , Fatores de Tempo , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico
3.
J Surg Res ; 248: 62-68, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31865160

RESUMO

BACKGROUND: Incidental findings (IFs) are common among injured patients and create a complex problem with no standardized solution. MATERIALS AND METHODS: This is a retrospective review of adult trauma patients admitted to a level I trauma center from January to May 2017. IFs from abdominal, chest, and neck imaging were categorized based on previously published guidelines focused on clinically significant IFs. Patient demographics related to access to care were collected. Outcome measures included documentation and patient notification of IFs. A univariate analysis was performed to identify characteristics that were associated with these outcomes. RESULTS: Of 1671 patients, 682 met inclusion criteria, and 418 (61.3%) had any IF based on the a priori categorization scheme. In total, 67 (9.8%) were homeless, 58 (8.5%) had no health insurance, and 115 (16.9%) had no established primary care provider prior to admission. Documentation of IFs was included in discharge summaries and instructions 76.5% and 40.2% of the time, respectively. Physicians were statistically more likely to appropriately document IFs when radiologists provided specific recommendations. Transfer to another hospital service prior to discharge and discharge to another acute care facility were associated with reduced rates of successful documentation. No factors significantly affected documentation of patient notification. CONCLUSIONS: Trauma patients are at risk for poor access to follow-up care of IFs. Expanding IF-specific guidelines, collaborating with radiologists to facilitate their inclusion in reports, and ensuring that IFs are part of patient hand-offs could provide systematic methods of improving their documentation.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31804420

RESUMO

BACKGROUND: Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) and intermittent-REBOA (iREBOA) are techniques to extend the therapeutic duration of REBOA by balloon titration for distal flow or cyclical balloon inflation/deflation to allow transient distal flow, respectively. We hypothesized that manually-titrated pREBOA would reduce blood losses and ischemic burden when compared to iREBOA. METHODS: Following 20% blood volume controlled hemorrhage, 10 anesthetized pigs underwent uncontrolled hemorrhage from the right iliac artery and vein. Once in hemorrhagic shock, animals underwent 15 minutes of complete Zone 1 REBOA followed by 75 minutes of either pREBOA or iREBOA (N=5/group). After 90 minutes, definitive hemorrhage control was obtained, animals were resuscitated with the remaining collected blood, and then received 2 hours of critical care. RESULTS: There were no differences in mortality. Animals randomized to iREBOA spent a larger portion of the time at full occlusion when compared to pREBOA (median [IQR]; 70 minutes [70, 80] versus 20 minutes [20, 40] respectively; p=0.008). While the average blood pressure during the intervention period was equivalent between groups, this was offset by large fluctuations in blood pressure and significantly more rescue occlusions for hypotension with iREBOA. Despite lower maximum aortic flow rates, the pREBOA group tolerated a greater total amount of distal aortic flow during the intervention period (median [IQR]; 20.9 L [20.1-23.0] vs 9.8 L [6.8-10.3]; p=0.03) with equivalent abdominal blood losses. Final plasma lactate and creatinine concentrations were equivalent, although iREBOA animals had increased duodenal edema on histology. CONCLUSION: Compared to iREBOA, pREBOA reduced the time spent at full occlusion and the number of precipitous drops in proximal MAP while delivering more distal aortic flow but not increasing total blood loss in this highly lethal injury model. Neither technique demonstrated a survival benefit. Further refinement of these techniques is necessary before clinical guidelines are issued. LEVEL OF EVIDENCE: III STUDY TYPE: Therapeutic.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31576422

RESUMO

PURPOSE: While resuscitative endovascular balloon occlusion of the aorta (REBOA) is contraindicated in patients with aortic injuries, this technique may benefit poly-trauma patients with less extreme thoracic injuries. The purpose of this study was to characterize the effects of thoracic injury on hemodynamics during REBOA and the changes in pulmonary contusion over time in a swine model. METHODS: Twelve swine were anesthetized, instrumented, and randomized to receive either a thoracic injury with 5 impacts to the chest or no injury. All animals underwent controlled hemorrhage of 25% blood volume followed by 45 min of Zone 1 REBOA. Animals were then resuscitated with shed blood, observed during a critical care period, and euthanized after 6 h of total experimental time. RESULTS: There were no differences between the groups at baseline. The only difference after 6 h was a lower hemoglobin in the thoracic trauma group (8.4 ± 0.8 versus 9.4 ± 0.6 g/dL, P = 0.04). The average proximal mean arterial pressures were significantly lower in the thoracic trauma group during aortic occlusion [103 (98-108) versus 117 (115-124) mmHg, P = 0.04]. There were no differences between the pulmonary contusion before REBOA and at the end of the experiment in size (402 ± 263 versus 356 ± 291 mL, P = 0.782) or density (- 406 ± 127 versus - 299 ± 175 HFU, P = 0.256). CONCLUSIONS: Thoracic trauma blunted the proximal arterial pressure augmentation during REBOA but had minimal impacts on resuscitative outcomes. This initial study indicates that REBOA does not seem to exacerbate pulmonary contusion in swine, but blunt thoracic injuries may attenuate the expected rises in proximal blood pressure during REBOA.

6.
Shock ; 2019 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-31389905

RESUMO

INTRODUCTION: Tranexamic acid (TXA) improves survival in traumatic hemorrhage, but difficulty obtaining intravenous (IV) access may limit its use in austere environments, given its incompatibility with blood products. The bioavailability of intramuscular (IM) TXA in a shock state is unknown. We hypothesized that IM and IV administration have similar pharmacokinetics and ability to reverse in vitro hyperfibrinolysis in a swine controlled-hemorrhage model. METHODS: Twelve Yorkshire cross swine were anesthetized, instrumented, and subjected to a 35% controlled hemorrhage, followed by resuscitation. During hemorrhage, they were randomized to receive a 1 g IV TXA infusion over 10 minutes, 1 g IM TXA in two 5 mL injections, or 10 mL normal saline IM injection as a placebo group to assess model adequacy. Serum TXA concentrations were determined using liquid chromatography-mass spectrometry, and plasma samples supplemented with tissue plasminogen activator (tPA) were analyzed by rotational thromboelastometry (ROTEM). RESULTS: All animals achieved class III shock. There was no difference in the concentration-time areas under the curve (AUC) between TXA given by either route. The absolute bioavailability of IM TXA was 97%. IV TXA resulted in a higher peak serum concentration during the infusion, with no subsequent differences. Both IV and IM TXA administration caused complete reversal of in vitro tPA-induced hyperfibrinolysis. CONCLUSION: The pharmacokinetics of IM TXA were similar to IV TXA during hemorrhagic shock in our swine model. IV administration resulted in a higher serum concentration only during the infusion, but all levels were able to successfully correct in vitro hyperfibrinolysis. There was no difference in total body exposure to equal doses of TXA between the two routes of administration. IM TXA may prove beneficial in scenarios where difficulty establishing dedicated IV access could otherwise limit or delay its use.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA