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1.
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
2.
Platelets ; 31(1): 94-102, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30810451

RESUMO

The aim of this study was to investigate the association between nadir platelet count and acute kidney injury (AKI) or 28-day all-cause mortality induced by hemorrhagic shock (HS), and to determine the cutoff value of nadir platelet count in HS clinical practice. This retrospective study included hospitalized patients enrolled in a tertiary-care teaching hospital from January 1, 2010 to December 31, 2015. Clinical data from HS admitted to the intensive care unit (ICU) were evaluated. Nadir platelet count was defined as the lowest values in the first 48 h. Multivariate logistic regression and Cox proportional hazards regression were used to assess the correlation between nadir platelet count and AKI or 28-day all-cause mortality induced by HS, respectively; the area under receiver operating characteristic (AU-ROC) and Youde's index were used to determine the optimal cutoff value of nadir platelet count. Kaplan-Meier's method and log-rank test were assessed for the 28-day all-cause mortality in AKI and non-AKI groups. Of 1589 patients screened, 84 patients (mean age,37.1 years; 58 males) were included in the primary analysis in which 30 patients with AKI. Multiple logistic results indicated that nadir platelet count was a risk factor of AKI (OR = 0.71,95% confidence interval [CI] 0.54-0.93, P < 0.05). Cox regression analysis revealed that nadir platelet count was independent risk factors for 28-day all-cause mortality (Hazard ratios [HR]0.89,95%CI 0.76-0.99, P < 0.05). Kaplan-Meier curve showed that 28-day all-cause mortality was significantly higher in patients with AKI than non-AKI (P < 0.001).These results suggest that nadir platelet count in the first 48 h is a new biomarker for AKI and 28-day all-cause mortality induced by HS. Moreover, the risk for AKI and 28-day all-cause mortality in HS patients decreased by 29% and 11%, respectively, for every 10 × 109/L increase in platelet count. Additional studies are needed to investigate whether elevation of nadir platelet count reduces the risk in different genders.


Assuntos
Lesão Renal Aguda/sangue , Lesão Renal Aguda/etiologia , Biomarcadores , Contagem de Plaquetas , Choque Hemorrágico/complicações , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue , Causas de Morte , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Adulto Jovem
3.
Am J Surg ; 218(6): 1169-1174, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31540684

RESUMO

INTRODUCTION: The aim of our study was to evaluate if pre-hospital shock index (SI) can predict transfusion requirements, resource utilization and mortality in trauma patients. METHODS: We performed a 2-year analysis of all adult trauma patients in the TQIP database. Shock index was calculated by dividing heart-rate over systolic blood pressure. Patients were divided into two groups pre-hospital SI ≤ 1 and prehospital SI > 1. Regression and ROC curve analyses were performed. RESULTS: 144951 patients were included in the study. Mean age was 45 ±â€¯34 years, 61% were male, 84.7% had blunt injuries and median ISS was 13 [9-17]. Overall 9.1% of the patients had a pre-hospital SI > 1. Patients with pre-hospital SI > 1 had higher likelihood of requiring massive transfusion (25% vs. 0.012%, p < 0.02), interventional-radiology intervention (6.2% vs. 1%,p < 0.001) or operative intervention (14.7% vs. 2%,p < 0.001) compared to SI ≤ 1. Similarly, patients with SI > 1 had higher mortality (12.3% vs. 5.2%, p < 0.001) and were more likely to be discharged to Rehab/SNF (34.6% vs. 21.4%, p < 0.001). CONCLUSIONS: Pre-hospital SI predicts trauma-center resource utilization and can guide patient triage and trauma resource recruitment.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Ferimentos e Lesões/complicações , Adulto , Serviços Médicos de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Triagem , Sinais Vitais
4.
J Surg Res ; 244: 69-76, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31279996

RESUMO

BACKGROUND: Acute hemorrhage-induced excessive excitation of sympathetic-adrenal-medullary system (SAS) leads to gut hypoperfusion and barrier dysfunction, which is a critical event during hemorrhagic shock-induced multiple organ injury. Stellate ganglion blockade (SGB) has been widely used for suppression of sympathetic-adrenal-medullary system in the clinical practice. However, whether SGB improves intestinal barrier function after hemorrhagic shock remains unclear. Here, we hypothesized that the implementation of SGB restores intestinal barrier function and reduces gut injury. MATERIALS AND METHODS: Male rats received the SGB pretreatment and underwent hemorrhagic shock followed by resuscitation. The 96-h survival rate, intestinal permeability and morphology, D-lactic acid concentration and diamine oxidase activity in plasma, and expressions of F-actin, Claudin-1, and E-cadherin in intestinal tissues were observed. RESULTS: Pretreatment with SGB significantly enhances the 96-h survival rate in rats subjected to hemorrhagic shock (from 8.3% to 66.7%). Hemorrhagic shock reduced the coverage scale of intestinal mucus and intestinal villus width and height, enhanced the intestinal permeability to fluorescein isothiocyanate-dextran 4 and D-lactic acid concentration in plasma, and decreased the expressions of F-actin, Claudin-1, and E-Cadherin in intestinal tissue. These hemorrhagic shock-induced adverse effects were abolished by SGB treatment. CONCLUSIONS: SGB treatment has a beneficial effect during hemorrhagic shock, which is associated with the improvement of intestine barrier function. SGB may be considered as a new therapeutic strategy for treatment of hemorrhagic shock.


Assuntos
Enteropatias/prevenção & controle , Mucosa Intestinal/patologia , Bloqueio Nervoso/métodos , Choque Hemorrágico/terapia , Gânglio Estrelado/efeitos dos fármacos , Anestésicos Locais/administração & dosagem , Animais , Modelos Animais de Doenças , Enteropatias/etiologia , Enteropatias/patologia , Mucosa Intestinal/inervação , Masculino , Permeabilidade/efeitos dos fármacos , Ratos , Ratos Sprague-Dawley , Ressuscitação , Ropivacaina/administração & dosagem , Choque Hemorrágico/complicações , Choque Hemorrágico/mortalidade , Organismos Livres de Patógenos Específicos , Taxa de Sobrevida , Resultado do Tratamento
5.
Transfus Clin Biol ; 26(3): 174-179, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31262629

RESUMO

Whole blood, that is blood that is not manufactured into its component red blood cells (RBC) plasma, and platelets (PLT) units, was the mainstay of transfusion for many years until it was discovered that the component parts of a blood donation could be stored under different conditions thereby optimizing the storage length of each product. The use of low anti-A and -B titer group O whole blood (LTOWB) has recently been rediscovered for use in massively bleeding trauma patients. Whole blood has several advantages over conventional component therapy for these patients, including simplifying the logistics of the resuscitation, being more concentrated than whole blood that is reconstituted from conventional components, and providing cold-stored PLTs, amongst other benefits. While randomized controlled trials to determine the efficacy of using LTOWB in the resuscitation of massively bleeding trauma patients are currently underway, retrospective data has shown that massively bleeding recipients of LTOWB with traumatic injury do not have worse outcomes compared to patients who received conventional components and, in some cases, recipients of LTOWB have more favourable outcomes. This paper will describe some of the advantages of using LTOWB and will discuss the emerging evidence for its use in massively bleeding patients.


Assuntos
Transfusão de Sangue/métodos , Hemorragia/terapia , Doença Aguda , Anticoagulantes/efeitos adversos , Tipagem e Reações Cruzadas Sanguíneas/métodos , Preservação de Sangue/métodos , Substitutos Sanguíneos/efeitos adversos , Substitutos Sanguíneos/uso terapêutico , Citratos/efeitos adversos , Soluções Cristaloides/efeitos adversos , Soluções Cristaloides/uso terapêutico , Serviços Médicos de Emergência , Glucose/efeitos adversos , Hemorragia/etiologia , Humanos , Procedimentos de Redução de Leucócitos , Ressuscitação , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Reação Transfusional/prevenção & controle , Resultado do Tratamento , Ferimentos e Lesões/complicações
6.
Khirurgiia (Mosk) ; (5): 31-37, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31169816

RESUMO

AIM: To identify risk factors of adverse outcomes in patients with nonvariceal upper gastrointestinal bleeding. MATERIAL AND METHODS: Epidemiological observational analytical longitudinal retrospective cohort study included 312 patients who were hospitalized in the Clinical Hospital #40 of Yekaterinburg in 2014-2016. The main inclusion criterion was nonvariceal upper gastrointestinal bleeding. RESULTS: In-hospital mortality was 31 (9.9%) of 312 patients. Multivariate analysis confirmed the following risk factors of mortality: severity of blood loss (OR 22.70, 95% CI 5.08-102.00); open surgery (OR 15.20, 95% CI 2.71-74.80); M. Charlson comorbidity index (OR 2.15, 95% CI 1.34-3.43); risk of recurrent bleeding according to T. Rockall scale (OR 1.76, 95% CI 1.18-2.64). CONCLUSION: Independent risk factors of adverse outcomes in patients with nonvariceal upper gastrointestinal bleeding are severe hemorrhagic shock, open surgery, high M. Charlson comorbidity index and risk of recurrent bleeding according to T. Rockall scale.


Assuntos
Hemorragia Gastrointestinal/epidemiologia , Comorbidade , Varizes Esofágicas e Gástricas/epidemiologia , Hemorragia Gastrointestinal/mortalidade , Mortalidade Hospitalar , Humanos , Estudos Longitudinais , Recidiva , Estudos Retrospectivos , Fatores de Risco , Federação Russa/epidemiologia , Prevenção Secundária/estatística & dados numéricos , Choque Hemorrágico/epidemiologia , Choque Hemorrágico/mortalidade
7.
J Trauma Acute Care Surg ; 87(3): 606-613, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31162330

RESUMO

BACKGROUND: Noncompressible torso hemorrhage is a leading cause of traumatic death. Our aim was to examine survival time and the expression of key master genes of cellular metabolism after 3% NaCl adenosine, lidocaine, and Mg (ALM) bolus and 4 hours 0.9% NaCl/ALM "drip" in a rat model of uncontrolled hemorrhagic shock. METHODS: Male Sprague-Dawley rats (425 ± 8 g) were anesthetized and randomly assigned to saline controls (n = 10) or ALM therapy (n = 10). Hemorrhage was induced by liver resection (60% left lateral lobe). After 15 minutes, a single intravenous bolus of 3% NaCl ± ALM (0.7 mL/kg) was administered (Phase 1), and after 60 minutes, a 0.9% NaCl ± ALM stabilization "drip" (0.5 mL/kg per hour) was infused for 4 hours (Phase 2) with 72 hours monitoring. Mean arterial pressure and lactate were measured. After 72 hours (or high moribund score), tissues were freeze-clamped and stored at -80°C. Total RNA was extracted in heart, brain, and liver, and the relative expressions of amp-k, mtCO3, PGC-1α, and sirt-1 genes were determined. RESULTS: Kaplan-Meier survival curves showed that controls had a mean survival time of 22.6 ± 4.5 hours, and ALM animals, 72 ± 0 hours (p < 0.05). Death in controls was accompanied by approximately sevenfold increase in lactate, while ALM animals maintained lactates similar to baseline over 72 hours. The relative expression of amp-k, PGC-1α, and sirt-1 in heart and brain was 1.5-fold and 2.7-fold higher in the ALM group compared with controls (p < 0.05), with the exception of mitochondrial encoded cytochrome C oxidase III pseudogene 1 in heart, which was 19-fold higher. In contrast, amp-k, sirt-1, and mtCO3 gene expression in liver was significantly 29-41% lower in the ALM group compared with controls, and PGC-1α was 75% lower. CONCLUSION: Small-volume ALM therapy led to 3.3-times longer survival time compared with saline controls after hemorrhagic shock. A hallmark of the ALM-survival phenotype in heart and brain was an upregulation of amp-k, PGC-1α, sirt-1, and mtCO3 to presumably "boost" mitochondrial function and ATP production, and a contrasting downregulation in liver. These central-peripheral differences in gene expression require further investigation.


Assuntos
Adenosina/uso terapêutico , Hidratação/métodos , Lidocaína/uso terapêutico , Magnésio/uso terapêutico , Choque Hemorrágico/terapia , Adenosina/administração & dosagem , Animais , Modelos Animais de Doenças , Expressão Gênica/efeitos dos fármacos , Perfilação da Expressão Gênica , Lidocaína/administração & dosagem , Magnésio/administração & dosagem , Masculino , Ratos , Ratos Sprague-Dawley , Reação em Cadeia da Polimerase em Tempo Real , Choque Hemorrágico/tratamento farmacológico , Choque Hemorrágico/metabolismo , Choque Hemorrágico/mortalidade , Fatores de Tempo
8.
J Trauma Acute Care Surg ; 87(2): 393-401, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31206419

RESUMO

BACKGROUND: Although damage control resuscitation (DCR) is routinely performed for short durations, prolonged DCR may be required in military conflicts as a component of prolonged field care. Valproic acid (VPA) has been shown to have beneficial properties in lethal hemorrhage/trauma models. We sought to investigate whether the addition of a single dose of VPA to a 72-hour prolonged DCR protocol would improve clinical outcomes. METHODS: Fifteen Yorkshire swine (40-45 kg) were subjected to lethal (50% estimated total blood volume) hemorrhagic shock (HS) and randomized to three groups: (1) HS, (2) HS-DCR, (3) HS-DCR-VPA (150 mg/kg over 3 hours) (n = 5/cohort). In groups assigned to receive DCR, Tactical Combat Casualty Care guidelines were applied (1 hour into the shock period), targeting a systolic blood pressure of 80 mm Hg. At 72 hours, surviving animals were given transfusion of packed red blood cells, simulating evacuation to higher echelons of care. Survival rates, physiologic parameters, resuscitative fluid requirements, and laboratory profiles were used to compare the clinical outcomes. RESULTS: This model was 100% lethal in the untreated animals. DCR improved survival to 20%, although this was not statistically significant. The addition of VPA to DCR significantly improved survival to 80% (p < 0.01). The VPA-treated animals also had significantly (p < 0.05) higher systolic blood pressures, lower fluid resuscitation requirements, higher hemoglobin levels, and lower creatinine and potassium levels. CONCLUSION: VPA administration improves survival, decreases resuscitation requirements, and improves hemodynamic and laboratory parameters when added to prolonged DCR in a lethal hemorrhage model.


Assuntos
Ressuscitação/métodos , Choque Hemorrágico/terapia , Ácido Valproico/uso terapêutico , Animais , Pressão Sanguínea/efeitos dos fármacos , Modelos Animais de Doenças , Feminino , Frequência Cardíaca/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Choque Hemorrágico/tratamento farmacológico , Choque Hemorrágico/mortalidade , Suínos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/tratamento farmacológico , Ferimentos e Lesões/terapia
9.
J Trauma Acute Care Surg ; 87(1): 68-75, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30985476

RESUMO

BACKGROUND: Adenosine, lidocaine, and magnesium (ALM) is a cardioplegic agent shown to improve survival by improving cardiac function, tissue perfusion, and coagulopathy in animal models of shock. We hypothesized prehospital ALM treatment in hemorrhagic shock would improve survival compared to current Tactical Combat Casualty Care (TCCC) resuscitation beyond the golden hour. METHODS: Swine were randomized to: (1) TCCC, (2) 2 mL·kg vehicle control (VC), (3) 2 mL·kg ALM + drip, (4) 4 mL·kg ALM + drip, 5) 4 mL·kg ALM + delayed drip at 0.5 mL·kg·h, 6) 4 mL/kg VC, 7) 4 mL·kg ALM for 15 minutes + delayed drip at 3 mL·kg·h. Animals underwent pressure controlled hemorrhage to mean arterial pressure (MAP) of 30 mm Hg (S = 0). Treatment was administered at T = 0. After 120 minutes of simulated prehospital care (T = 120) blood product resuscitation commenced. Physiologic variables were recorded and laboratories were drawn at specified time points. RESULTS: Tactical Combat Casualty Care demonstrated superior survival to all other agents. The VC and ALM groups had lower MAPs and systolic blood pressures compared with TCCC. Except for the VC groups, lactate levels remained similar with correction of base deficit after prehospital resuscitation in all groups. Kidney function and liver function remained comparable across all groups. Compared with baseline values, TCCC demonstrated significant hypocoagulability. CONCLUSION: Adenosine, lidocaine, and magnesium, as administered in this study, are inferior to current Hextend-based resuscitation for survival from prolonged hemorrhagic shock in this model. In survivors, ALM groups had lower systolic blood pressures and MAPs, but provided a protective effect on coagulopathy as compared to TCCC. Adenosine, lidocaine, and magnesium do not appear to be a suitable low volume replacement to current TCCC resuscitation. The reduced coagulopathy compared to TCCC warrants future studies of ALM, perhaps as a therapeutic adjunct.


Assuntos
Adenosina/uso terapêutico , Soluções Cardioplégicas/uso terapêutico , Serviços Médicos de Emergência/métodos , Lidocaína/uso terapêutico , Magnésio/uso terapêutico , Medicina Militar/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Adenosina/administração & dosagem , Animais , Soluções Cardioplégicas/administração & dosagem , Modelos Animais de Doenças , Lidocaína/administração & dosagem , Magnésio/administração & dosagem , Masculino , Ressuscitação/mortalidade , Choque Hemorrágico/mortalidade , Suínos , Ferimentos e Lesões/mortalidade
10.
Biochim Biophys Acta Mol Basis Dis ; 1865(3): 688-695, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30625381

RESUMO

Inflammation and cellular energetics play critical roles in organ dysfunction following hemorrhagic shock. Recent studies suggest a putative role for sirtuin 1 (SIRT1) in potentiating mitochondrial function and improving organ function following hemorrhagic shock in animal models. SIRT1 is an NAD+ dependent protein deacetylase and increased availability of NAD+ has been shown to augment SIRT1 activity. As niacin is a precursor of NAD+, in this study, we tested whether niacin can improve survival following hemorrhagic shock. However niacin also mediates its biological action by binding to its receptor, hydroxyl-carboxylic acid receptor 2 (HCA2 or Gpr109a); so we examined whether the effect of niacin is mediated by binding to Gpr109a or by increasing NAD+ availability. We found that niacin administered intravenously to rats subjected to hemorrhagic injury (HI) in the absence of fluid resuscitation resulted in a significantly prolonged duration of survival. However, treatment of rats with similar doses of nicotinamide mononucleotide (NMN), a precursor to NAD+ that does not bind Gpr109a, did not extend survival following HI. The duration of survival due to niacin treatment was significantly reduced in Gpr109a-/- mice subjected to HI. These experiments demonstrated that the Gpr109a receptor-mediated pathway contributed significantly to niacin mediated salutary effect. Further studies showed improvement in markers of cellular energetics and attenuation of inflammatory response with niacin treatment. In conclusion, we report that Gpr109a-dependent signalling is important in restoring cellular energetics and immunometabolism following hemorrhagic shock.


Assuntos
Niacina/uso terapêutico , Receptores Acoplados a Proteínas-G/genética , Choque Hemorrágico/tratamento farmacológico , Animais , Mucosa Intestinal/efeitos dos fármacos , Mucosa Intestinal/metabolismo , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Miocárdio/metabolismo , Miocárdio/patologia , NAD/metabolismo , NADP/metabolismo , Niacina/metabolismo , Permeabilidade/efeitos dos fármacos , Receptores Acoplados a Proteínas-G/metabolismo , Choque Hemorrágico/genética , Choque Hemorrágico/mortalidade , Choque Hemorrágico/patologia , Transdução de Sinais/efeitos dos fármacos , Transdução de Sinais/genética , Análise de Sobrevida
11.
Can J Surg ; 62(1): E17-E18, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30694036

RESUMO

Summary: Expediting life-saving care for hemorrhagic shock through multi-disciplinary code protocols is a potential method to improve outcomes. Trauma codes have become standard of care at most tertiary care centres; however, it is unclear if similar protocols can improve delivery of care for other forms of hemorrhagic shock. We examined the feasibility of a code protocol for ruptured abdominal aortic aneurysms (RAAAs) by reviewing the literature and comparing patient outcomes for RAAA and trauma patients at our institution, where the latter have a wellestablished trauma code protocol. We show that, despite being similarly unstable, patients with RAAA experienced delays to care milestones compared with trauma patients, even when accounting for diagnostic delays. Combining these data with present understanding of factors implicated in RAAA survival, we propose that a "CodeAAA" protocol may fill an important gap in RAAA care and that further prospective studies examining the utility of such a code are warranted.


Assuntos
Aneurisma Roto/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/métodos , Choque Hemorrágico/cirurgia , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/complicações , Aneurisma Roto/diagnóstico , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/mortalidade , Canadá , Estudos de Coortes , Emergências , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Classificação Internacional de Doenças , Masculino , Prognóstico , Estudos Retrospectivos , Medição de Risco , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Análise de Sobrevida , Centros de Traumatologia , Resultado do Tratamento
12.
J Surg Res ; 233: 132-138, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30502239

RESUMO

BACKGROUND: Tranexamic acid (TXA) has been shown to reduce mortality in the treatment of traumatic hemorrhage. This effect seems most profound when given early after injury. We hypothesized that extending a protocol for TXA administration into the prehospital aeromedical setting would improve outcomes while maintaining a similar safety profile to TXA dosed in the emergency department (ED). MATERIALS AND METHODS: We identified all trauma patients who received TXA during prehospital aeromedical transport or in the ED at our urban level I trauma center over an 18-mo period. These patients had been selected prospectively for TXA administration using a protocol that selected adult trauma patients with high-risk mechanism and concern for severe hemorrhage to receive TXA. Patient demographics, vital signs, lab values including thromboelastography, blood administration, mortality, and complications were reviewed retrospectively and analyzed. RESULTS: One hundred sixteen patients were identified (62 prehospital versus 54 ED). Prehospital TXA patients were more likely to have sustained blunt injury (76% prehospital versus 46% ED, P = 0.002). There were no differences between groups in injury severity score or initial vital signs. There were no differences in complication rates or mortality. Patients receiving TXA had higher rates of venous thromboembolic events (8.1% in prehospital and 18.5% in ED) than the overall trauma population (2.1%, P < 0.001). CONCLUSIONS: Prehospital administration of TXA during aeromedical transport did not improve survival compared with ED administration. Treatment with TXA was associated with increased risk of venous thromboembolic events. Prehospital TXA protocols should be refined to identify patients with severe hemorrhagic shock or traumatic brain injury.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Antifibrinolíticos/administração & dosagem , Serviço Hospitalar de Emergência/estatística & dados numéricos , Choque Hemorrágico/terapia , Ácido Tranexâmico/administração & dosagem , Tromboembolia Venosa/epidemiologia , Adulto , Antifibrinolíticos/efeitos adversos , Transfusão de Sangue/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Tromboelastografia , Fatores de Tempo , Ácido Tranexâmico/efeitos adversos , Resultado do Tratamento , Tromboembolia Venosa/induzido quimicamente , Tromboembolia Venosa/diagnóstico , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Adulto Jovem
13.
Eur J Trauma Emerg Surg ; 45(5): 865-870, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30264328

RESUMO

BACKGROUND: Extremities are commonly injured following bomb explosions. The main objective of this study was to evaluate the prevalence of hemorrhagic shock (HS) in victims of explosion suffering from extremity injuries. METHODS: Retrospective study based on a cohort of patient records maintained in one hospital's mass casualty registry. RESULTS: Sixty-six victims of explosion who were hospitalized with extremity injuries were identified and evaluated. Sixteen (24.2%) of these were hemodynamically unstable during the first 24 h of treatment. HS could be attributed to associated injuries in seven of the patients. In the other nine patients, extremity injury was the only injury that could explain HS in seven patients and the extremity injury was a major contributor to HS together with another associated injury in two patients. In those 9 patients, in whom the extremity injury was the sole or major contributor to HS, a median of 10 (range 2-22) pRBC was transfused during the first 24 h of treatment. Six of the nine patients were in need of massive transfusion. Fractures in both upper and lower extremities, Gustilo IIIb-c open fractures and AIS 3-4 were found to be risk factors for HS. CONCLUSIONS: Ample consideration should be given to patients with extremity injuries due to explosions, as these may be immediately life threatening. Tourniquet use should be encouraged in the pre-hospital setting. Before undertaking surgery, emergent HS should be considered in these patients and prevented by appropriate resuscitation.


Assuntos
Traumatismos por Explosões/fisiopatologia , Hemorragia/fisiopatologia , Incidentes com Feridos em Massa/mortalidade , Choque Hemorrágico/mortalidade , Terrorismo , Centros de Traumatologia , Adolescente , Adulto , Traumatismos por Explosões/complicações , Traumatismos por Explosões/terapia , Bombas (Dispositivos Explosivos) , Criança , Feminino , Hemodinâmica , Hemorragia/complicações , Hemorragia/cirurgia , Humanos , Escala de Gravidade do Ferimento , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Torniquetes , Adulto Jovem
14.
Eur J Emerg Med ; 26(5): 373-378, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30531322

RESUMO

BACKGROUND: Early transfusion of patients with major traumatic haemorrhage may improve survival. This study aims to establish the feasibility of freeze-dried plasma transfusion in a Helicopter Emergency Medical Service in the UK. PATIENTS AND METHODS: A retrospective observational study of major trauma patients attended by Kent, Surrey and Sussex Helicopter Emergency Medical Service and transfused freeze-dried plasma since it was introduced in April 2014. RESULTS: Of the 1873 patients attended over a 12-month period before its introduction, 79 patients received packed red blood cells (4.2%) with a total of 193 units transfused. Of 1881 patients after the introduction of freeze-dried plasma, 10 patients received packed red blood cells only and 66 received both packed red blood cells and freeze-dried plasma, with a total of 158 units of packed red blood cells transfused, representing an 18% reduction between the two 12-month periods. In the 20 months since its introduction, of 216 patients transfused with at least one unit of freeze-dried plasma, 116 (54.0%) patients received both freeze-dried plasma and packed red blood cells in a 1: 1 ratio. Earlier transfusion was feasible, transferring the patient to the hospital before transfusion would have incurred a delay of 71 min (interquartile range: 59-90 min). CONCLUSION: Prehospital freeze-dried plasma and packed red blood cell transfusion is feasible in a 1: 1 ratio in patients with suspected traumatic haemorrhage. The use of freeze-dried plasma as a first-line fluid bolus reduced the number of prehospital packed red blood cell units required and reduced the time to transfusion.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Transfusão de Eritrócitos/métodos , Plasma , Choque Hemorrágico/terapia , Adulto , Transfusão de Sangue/métodos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Ressuscitação/métodos , Estudos Retrospectivos , Medição de Risco , Choque Hemorrágico/mortalidade , Análise de Sobrevida , Resultado do Tratamento , Reino Unido
15.
Injury ; 50(2): 318-323, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30448330

RESUMO

BACKGROUND: Due to the challenge of identifying need for intervention in bleeding patients, there is a growing interest in prediction modeling. Massive transfusion (MT; 10 or more packed red cells in 24 h) is the most commonly studied dependent variable, serving as a surrogate for severe bleeding and its prediction guides the need for intervention. The critical administration threshold (CAT; 3 packed red cells in 1 h) has been proposed as an alternative. In this study, we aim to compare the classification accuracy of these two surrogates for hemorrhage-related outcomes in health administrative datasets. METHODS: We performed a secondary analysis of major trauma patients from the prospectively collected Ottawa Trauma Registry, from September 2014 to September 2017. We conducted a logistic regression analysis utilizing need for hemostasis or hemorrhagic death as dependent variables. We compared classification accuracy in terms of sensitivity, specificity, positive predictive value, negative predictive value and AUC. CAT + and MT + status is not mutually exclusive. RESULTS: We studied 890 major trauma patients, including 145 CAT + and 48 MT + patients. CAT + demonstrated a superior association for the composite outcome of 24-hour hemorrhage-related mortality and need for hemostasis (AUC 0.815 vs. 0.644, p < 0.0001). This performance was driven by a substantial difference in sensitivity, noted to be 70.0% (95% CI 62.1-77.9%) for CAT + but only 30.0% (95% CI 22.1-37.9%) for MT+. CAT + and MT + demonstrated specificities of 92.9% (95% CI 91.1-94.7%) and 98.9% (98.1-99.6%) respectively. CONCLUSION: This study illustrates the concepts of survivorship and competing risk bias for massive transfusion. Utilizing a composite outcome of need for hemostasis and early hemorrhagic death, we demonstrate that CAT + is more accurate for identifying significantly bleeding patients.


Assuntos
Transfusão de Sangue , Hemorragia/terapia , Sistema de Registros/estatística & dados numéricos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Adulto , Transfusão de Sangue/estatística & dados numéricos , Protocolos Clínicos , Feminino , Hemorragia/mortalidade , Hemostasia , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/mortalidade , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade
16.
Scand J Trauma Resusc Emerg Med ; 26(1): 107, 2018 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-30558650

RESUMO

BACKGROUND: Damage control strategies play an important role in trauma patient management. One such strategy, hypotensive resuscitation, is being increasingly employed. Although several randomized controlled trials have reported its benefits, the mortality benefit of hypotensive resuscitation has not yet been systematically reviewed. OBJECTIVES: To conduct a meta-analysis of the efficacy of hypotensive resuscitation in traumatic hemorrhagic shock patients relative to mortality as the primary outcome, with acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and multiple organ dysfunction as the secondary outcomes. METHODS: PubMed, Medline-Ovid, Scopus, Science Direct, EMBASE, and CNKI database searches were conducted. An additional search of relevant primary literature and review articles was also performed. Randomized controlled trials and cohort studies reporting the mortality rate associated with hypotensive resuscitation or limited fluid resuscitation were selected. The random-effects model was used to estimate mortality and onset of other complications. RESULTS: Of 2114 studies, 30 were selected for this meta-analysis. A statistically significant decrease in mortality was observed in the hypotensive resuscitation group (risk ratio [RR]: 0.50; 95% confidence interval [CI]: 0.40-0.61). Heterogeneity was observed in the included literature (I2: 27%; degrees of freedom: 23; p = 0.11). Less usage of packed red cell transfusions and fluid resuscitations was also demonstrated. No significant difference between groups was observed for AKI; however, a protective effect was observed relative to both multiple organ dysfunction and ARDS. CONCLUSIONS: This meta-analysis revealed significant benefits of hypotensive resuscitation relative to mortality in traumatic hemorrhagic shock patients. It not only reduced the need for blood transfusions and the incidences of ARDS and multiple organ dysfunction, but it caused a non-significant AKI incidence.


Assuntos
Hipotensão , Ressuscitação/métodos , Choque Hemorrágico/terapia , Choque Traumático/terapia , Lesão Renal Aguda/prevenção & controle , Transfusão de Eritrócitos/estatística & dados numéricos , Hidratação/estatística & dados numéricos , Humanos , Insuficiência de Múltiplos Órgãos/prevenção & controle , Síndrome do Desconforto Respiratório do Adulto/prevenção & controle , Choque Hemorrágico/mortalidade , Choque Traumático/mortalidade
17.
PLoS One ; 13(11): e0207708, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30496239

RESUMO

BACKGROUND: We hypothesized that slow crystalloid resuscitation would result in less blood loss and a smaller hemoglobin decrease compared to a rapid resuscitation during uncontrolled hemorrhage. METHODS: Anesthetized, splenectomized domestic swine underwent hepatic lobar hemitransection. Lactated Ringers was given at 150 or 20 mL/min IV (rapid vs. slow, respectively, N = 12 per group; limit of 100 mL/kg). Primary endpoints were blood loss and serum hemoglobin; secondary endpoints included survival, vital signs, coagulation parameters, and blood gases. RESULTS: The slow group had a less blood loss (1.6 vs. 2.7 L, respectively) and a higher final hemoglobin concentration (6.0 vs. 3.4 g/dL). CONCLUSIONS: Using a fixed volume of crystalloid resuscitation in this porcine model of uncontrolled intraabdominal hemorrhage, a slow IV infusion rate produced less blood loss and a smaller hemoglobin decrease compared to rapid infusion.


Assuntos
Hidratação , Lactato de Ringer/administração & dosagem , Choque Hemorrágico/terapia , Animais , Gasometria , Plaquetas/citologia , Pressão Sanguínea , Temperatura Corporal , Fibrinogênio/análise , Frequência Cardíaca , Hemoglobinas/análise , Infusões Intravenosas , Coeficiente Internacional Normatizado , Masculino , Necrose , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Esplenectomia/efeitos adversos , Taxa de Sobrevida , Suínos
18.
West J Emerg Med ; 19(6): 977-986, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30429930

RESUMO

Introduction: Hemorrhage is one of the leading causes of death in trauma victims. Historically, paramedics have not had access to medications that specifically target the reversal of trauma-induced coagulopathies. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to evaluate the safety and efficacy of tranexamic acid (TXA) use in the civilian prehospital setting in cases of traumatic hemorrhagic shock. Methods: The Cal-PAT study is a multi-centered, prospective, observational cohort study with a retrospective comparison. From March 2015 to July 2017, patients ≥ 18 years-old who sustained blunt or penetrating trauma with signs of hemorrhagic shock identified by first responders in the prehospital setting were considered for TXA treatment. A control group was formed of patients seen in the five years prior to data collection cessation (June 2012 to July 2017) at each receiving center who were not administered TXA. Control group patients were selected through propensity score matching based on gender, age, Injury Severity Scores, and mechanism of injury. The primary outcome assessed was mortality recorded at 24 hours, 48 hours, and 28 days. Additional variables assessed included total blood products transfused, the hospital and intensive care unit length of stay, systolic blood pressure taken prior to TXA administration, Glasgow Coma Score observed prior to TXA administration, and the incidence of known adverse events associated with TXA administration. Results: We included 724 patients in the final analysis, with 362 patients in the TXA group and 362 in the control group. Reduced mortality was noted at 28 days in the TXA group in comparison to the control group (3.6% vs. 8.3% for TXA and control, respectively, odds ratio [OR]=0.41 with 95% confidence interval [CI] [0.21 to 0.8]). This mortality difference was greatest in severely injured patients with ISS >15 (6% vs 14.5% for TXA and control, respectively, OR=0.37 with 95% CI [0.17 to 0.8]). Furthermore, a significant reduction in total blood product transfused was observed after TXA administration in the total cohort as well as in severely injured patients. No significant increase in known adverse events following TXA administration were observed. Conclusion: Findings from the Cal-PAT study suggest that TXA use in the civilian prehospital setting may safely improve survival outcomes in patients who have sustained traumatic injury with signs of hemorrhagic shock.


Assuntos
Antifibrinolíticos/administração & dosagem , Choque Hemorrágico/mortalidade , Choque Hemorrágico/terapia , Ácido Tranexâmico/administração & dosagem , Ferimentos e Lesões/complicações , Adolescente , Adulto , California/epidemiologia , Serviços Médicos de Emergência/métodos , Feminino , Escala de Resultado de Glasgow , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque Hemorrágico/etiologia , Fatores de Tempo , Adulto Jovem
19.
PLoS One ; 13(11): e0206991, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30395596

RESUMO

INTRODUCTION: Despite the use of a multidisciplinary treatment approach, the mortality rate of hemodynamic instability due to severe pelvic fracture remains 40-60%. Several recent studies have shown that preperitoneal pelvic packing (PPP) was useful for achieving hemostasis in these patients in the acute phase. However, few studies have examined postoperative complications. The purpose of the present study was to evaluate clinical outcomes and wound infections of PPP in these patients. MATERIALS AND METHODS: We retrospectively reviewed the medical charts of 62 patients with hemorrhagic shock due to pelvic fracture between March 2011 and May 2017. Excluding four patients (two with other major hemorrhage sites and two who experienced cardiac arrest in the emergency room), the patients were divided into PPP (n = 30) and non-PPP (n = 28) groups according to PPP application. Clinical outcomes including early-stage mortality, transfusion amount, and surgical site infection (SSI) were compared between the two groups. RESULTS: The overall mortality rate was 48.3% and the mean Injury Severity Score (ISS) was 39 ± 9. The 30 patients in the PPP group had a significantly lower hemorrhage-induced mortality rate than the 28 patients in the non-PPP group (16.7% vs 50%, p = 0.019), although both groups had similar patient characteristics (age, ISS, and initial serum lactate level). Independent factors associated with hemorrhage-induced mortality were PPP and the requirement of packed red blood cells for 4 h. In the PPP group, SSI occurred in 5 of 25 (20%) patients. CONCLUSIONS: PPP may be considered as a hemostatic modality for hemodynamic instability due to pelvic fracture because it reduces the hemorrhage-induced mortality rate. However, wound infections after the procedure should be considered.


Assuntos
Fraturas Ósseas/patologia , Choque Hemorrágico/patologia , Infecção da Ferida Cirúrgica/diagnóstico , Adulto , Idoso , Feminino , Fraturas Ósseas/complicações , Fraturas Ósseas/cirurgia , Técnicas Hemostáticas/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Choque Hemorrágico/complicações , Choque Hemorrágico/mortalidade , Infecção da Ferida Cirúrgica/etiologia , Taxa de Sobrevida , Resultado do Tratamento
20.
Chin J Traumatol ; 21(5): 293-300, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30342984

RESUMO

PURPOSE: Renal denervation (RD) has been demonstrated to be an effective approach to reduce blood pressure for those with resistant hypertension. Yet, we aimed to explore the effect and possible mechanism of RD on blood-pressure response to hemorrhagic shock in spontaneously hypertensive rats. METHODS: A total of 48 male spontaneously hypertensive rats were randomized to three groups: study group, sham-operation group and control group. RD was achieved by cutting off renal nerves and swabbing phenol on it. Ten weeks after RD, 8 rats in each group were sacrificed to collect the kidney and heart tissues. The remaining rats were subjected to an operation to induce hemorrhagic shock which would lead to 40% loss of total blood volume, and observed for 120 min. The serum concentration of norepinephrine was measured before and three weeks after RD. RESULTS: The blood-pressure and norepinephrine levels were reduced significantly after RD (p < 0.05). Systolic blood pressure and diastolic blood pressure of the surgery group were higher than those in the sham and control groups at 15, 30 and 45 min after hemorrhagic shock (p < 0.05), while no significant difference was observed at 60, 90 and 120 min (p > 0.05). Additionally, the beta-1 adrenergic receptor (ß1-AR) in the study group was significantly higher than those in the other two groups (p < 0.05) after hemorrhagic shock. CONCLUSION: This study demonstrated that RD could to some extent improve blood-pressure response to hemorrhagic shock in an established model of severe hemorrhagic shock in spontaneously hypertensive rats. The mechanism might be associated with up-regulation of ß1-AR.


Assuntos
Hipertensão/prevenção & controle , Rim/inervação , Rim/cirurgia , Choque Hemorrágico/complicações , Simpatectomia/métodos , Análise de Variância , Animais , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial , Modelos Animais de Doenças , Hipertensão/mortalidade , Hipertensão/cirurgia , Masculino , Distribuição Aleatória , Ratos , Ratos Endogâmicos SHR , Valores de Referência , Fatores de Risco , Choque Hemorrágico/mortalidade , Taxa de Sobrevida , Resultado do Tratamento
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