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1.
Hematology ; 26(1): 601-611, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34411495

RESUMO

There has been renewed interest in the use of low titer group O whole blood (LTOWB) for the resuscitation of civilian casualties. LTOWB offers several advantages over conventional components such as providing balanced resuscitation in one bag that contains less additive/preservative solution than an equivalent volume of conventional components, is easier and faster to transfuse than multiple components, avoids blood product ratio confusion, contains cold stored platelets, and reduces donor exposures. The resurgence in its use in the resuscitation of civilian trauma patients has led to the publication of an increasing number of studies on its use, primarily amongst adult recipients but also in pediatric patients. These studies have indicated that hemolysis does not occur amongst adult and pediatric non-group O recipients of a modest quantity of LTOWB. The published studies to date on mortality have shown conflicting results with some demonstrating a reduction following LTOWB transfusion while most others have not shown a reduction; there have not been any studies to date that have found significantly increased overall mortality amongst LTOWB recipients. Similarly, when other clinical outcomes, such as venous thromboembolism, sepsis, hospital or intensive care unit lengths of stay are evaluated, LTOWB recipients have not demonstrated worse outcomes compared to conventional component recipients. While definitive proof of the trends in these morbidity and mortality outcomes awaits confirmation in randomized controlled trials, the evidence to date indicates the safety of transfusing LTOWB to injured civilians.


Assuntos
Transfusão de Sangue/métodos , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Sistema ABO de Grupos Sanguíneos/sangue , Doadores de Sangue , Preservação de Sangue , Humanos , Reação Transfusional , Resultado do Tratamento , Ferimentos e Lesões/sangue
3.
Transfusion ; 61 Suppl 1: S159-S166, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269430

RESUMO

BACKGROUND: The use of blood products early in the resuscitation of bleeding trauma patients is widely accepted, but made difficult by limited supplies of D- red blood cell (RBC)-containing products. Use of D+ RBC-containing products would alleviate this issue, but could lead to alloimmunization. Risk associated with transfusing D+ RBC in emergency bleeding situations is being reconsidered. The level of concern surrounding emergency transfusion as it relates to future fetal harm was surveyed among surgeons and nurses. METHODS: Faculty and staff in the Departments of Surgery and Nursing were surveyed on the risks of receiving an emergency RBC transfusion and the subsequent potential for fetal harm. Answers were grouped as likely to accept (likely/very likely) or refuse transfusion (unlikely/very unlikely). Participants were compared by sex, and women by child-bearing age, ([15-50 years] vs. [>50 years]). RESULTS: Ninety surveys were initiated with 76 fully completed. Male (n = 39) and female (n = 37) respondents were comparable. Most female respondents (30/37, 81%) were of childbearing age. Overall, both males (38/39, 95%) and females (33/37, 89%; p = .19) were likely to accept a transfusion in an emergency. There was no difference in transfusion acceptance if the risk of fetal harm was presented as 1% (p = .73) or 0.1% (p = .51). Most females (34/37, 92%) were not opposed to transfusion even if there was an unspecified risk of future fetal harm. CONCLUSION: Most of the surgeons and nurses who responded would accept a transfusion in an emergency situation even if it might lead to harming a future fetus.


Assuntos
Transfusão de Eritrócitos/efeitos adversos , Hemorragia/terapia , Reação Transfusional/etiologia , Ferimentos e Lesões/terapia , Adolescente , Adulto , Transfusão de Sangue/métodos , Transfusão de Eritrócitos/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Cooperação do Paciente , Gravidez , Ressuscitação/efeitos adversos , Ressuscitação/métodos , Medição de Risco , Cirurgiões , Inquéritos e Questionários , Centros de Traumatologia , Recusa do Paciente ao Tratamento , Adulto Jovem
4.
Transfusion ; 61 Suppl 1: S22-S31, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269432

RESUMO

BACKGROUND: Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use. STUDY DESIGN AND METHODS: Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff. RESULTS: Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion. DISCUSSION: The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding.


Assuntos
Transfusão de Sangue , Ressuscitação , Reação Transfusional/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/métodos , Criança , Pré-Escolar , Feminino , Hemólise , Hospitais , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Noruega/epidemiologia , Ressuscitação/métodos , Reação Transfusional/sangue , Reação Transfusional/patologia , Adulto Jovem
5.
Transfusion ; 61 Suppl 1: S252-S263, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269434

RESUMO

BACKGROUND: Multiple thresholds are defined to identify patients at risk of death from hemorrhage, including massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI). All fail to account for the use of whole blood (WB). We hypothesized that a definition including WB transfusion would better predict early mortality following trauma. METHODS: This is a retrospective review of all trauma patients with activation of the MT protocol from December 2018 to February 2020. Combinations of WB, RBCs, and fresh frozen plasma (FFP) units transfused during the initial hour of resuscitation were compared using receiver operating characteristic and area under the receiver curve (AUC) for 3- and 6-h mortality. WB massive transfusion (WB MT) score was defined as the sum of each unit RBC plus three times each unit of WB transfused within the first hour of resuscitation. RESULTS: There were 235 patients eligible for analysis with 60 resuscitated using ≥1 unit of WB. Overall, 27 and 29 patients died in the first 3 and 6 h, respectively. WB MT ≥7 had the greatest 3-h and 6-h mortality AUC values (0.78 and 0.79, respectively) when compared to MT, CAT, RI4+, and other attempted definitions using units of WB, RBC, and FFP. Compared to WB MT-, WB MT+ patients died at significantly higher rates at 3 h (28.9% vs. 3.1%, p < .001), 24 h (35.5% vs. 5.7%, p < .001), and 28 days (42.1% vs. 11.9%, p < .001). CONCLUSION: WB MT is the first measure of massive resuscitation to incorporate WB and better identifies early mortality than other definitions.


Assuntos
Transfusão de Sangue/métodos , Hemorragia/terapia , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Adulto , Feminino , Hemorragia/sangue , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ferimentos e Lesões/sangue , Ferimentos e Lesões/mortalidade
6.
Transfusion ; 61 Suppl 1: S333-S335, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269445

RESUMO

Hemorrhage is the most common mechanism of death in battlefield casualties with potentially survivable injuries. There is evidence that early blood product transfusion saves lives among combat casualties. When compared to component therapy, fresh whole blood transfusion improves outcomes in military settings. Cold-stored whole blood also improves outcomes in trauma patients. Whole blood has the advantage of providing red cells, plasma, and platelets together in a single unit, which simplifies and speeds the process of resuscitation, particularly in austere environments. The Joint Trauma System, the Defense Committee on Trauma, and the Armed Services Blood Program endorse the following: (1) whole blood should be used to treat hemorrhagic shock; (2) low-titer group O whole blood is the resuscitation product of choice for the treatment of hemorrhagic shock for all casualties at all roles of care; (3) whole blood should be available within 30 min of casualty wounding, on all medical evacuation platforms, and at all resuscitation and surgical team locations; (4) when whole blood is not available, component therapy should be available within 30 min of casualty wounding; (5) all prehospital medical providers should be trained and logistically supported to screen donors, collect fresh whole blood from designated donors, transfuse blood products, recognize and treat transfusion reactions, and complete the minimum documentation requirements; (6) all deploying military personnel should undergo walking blood bank prescreen laboratory testing for transfusion transmitted disease immediately prior to deployment. Those who are blood group O should undergo anti-A/anti-B antibody titer testing.


Assuntos
Transfusão de Sangue/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Bancos de Sangue/métodos , Serviços Médicos de Emergência/métodos , Humanos , Medicina Militar , Militares
7.
Transfusion ; 61 Suppl 1: S174-S182, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269446

RESUMO

BACKGROUND: The Compensatory Reserve Measurement (CRM) is a novel method used to provide early assessment of shock based on arterial wave form morphology changes. We hypothesized that (1) CRM would be significantly lower in those trauma patients who received life-saving interventions compared with those not receiving interventions, and (2) CRM in patients who received interventions would recover after the intervention was performed. STUDY DESIGN AND METHODS: We captured vital signs along with analog arterial waveform data from trauma patients meeting major activation criteria using a prospective study design. Study team members tracked interventions throughout their emergency department stay. RESULTS: Ninety subjects met inclusion with 13 receiving a blood product and 10 a major airway intervention. Most trauma was blunt (69%) with motor vehicle collisions making up the largest proportion (37%) of injury mechanism. Patients receiving blood products had lower CRM values just prior to administration versus those who did not (50% versus 58%, p = .045), and lower systolic pressure (SBP; 95 versus 123 mmHg, p = .005), diastolic (DBP; 62 versus 79, p = .007), and mean arterial pressure (MAP; 75 versus 95, p = .006), and a higher pulse rate (HR; 101 versus 89 bpm, p = .039). Patients receiving an airway intervention had lower CRM values just prior to administration versus those who did not (48% versus 58%, p = .062); however, SBP, DBP, MAP, and HR were not statistically distinguishable (p ≥ .645). CONCLUSIONS: Our results support our hypotheses that the CRM distinguished those patients who received blood or an airway intervention from those who did not, and increased appropriately after interventions were performed.


Assuntos
Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia , Adulto , Pressão Arterial , Pressão Sanguínea , Transfusão de Sangue , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Ressuscitação/métodos , Choque Traumático/diagnóstico , Choque Traumático/terapia , Ferimentos e Lesões/fisiopatologia
8.
Transfusion ; 61 Suppl 1: S294-S300, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269448

RESUMO

Massive bleeding remains a major source of morbidity and mortality worldwide. Recent studies have shed light on the pathophysiology of traumatic-induced coagulopathy and the central role of endotheliopathy. Transfusion therapy has changed dramatically in the last decade with use of red cells and plasma in a 1:1 ratio. The use of early transfusion increases the likelihood of a favorable outcome. Early intervention-preferably less than 60 min of injury-is a major factor in improved survival. Experience with dried plasma products-lyophilized or freeze-dried-in Europe and South Africa has demonstrated both safety and efficacy. Dry plasma products are not available in the United States but several products are in development. Spray-dried plasma contains clinically meaningful levels of coagulation activity and in vitro data suggest robust ability to generate thrombus. The decentralized, blood-center based manufacturing model of spray-dried plasma offers advantages for availability to meet routine and extraordinary demands.


Assuntos
Transfusão de Componentes Sanguíneos/métodos , Preservação de Sangue , Hemorragia/terapia , Plasma , Ferimentos e Lesões/terapia , Preservação de Sangue/métodos , Hemorragia/sangue , Humanos , Plasma/química , Ressuscitação/métodos , Secagem por Atomização , Ferimentos e Lesões/sangue
9.
Transfusion ; 61 Suppl 1: S43-S48, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269453

RESUMO

BACKGROUND: Low-titer group O whole-blood (LTOWB) is being used for children with life-threatening traumatic bleeding. A survey was conducted to determine current LTOWB utilization and interest in participation in a randomized control trial (RCT) of LTOWB versus standard blood component transfusion in this population. STUDY DESIGN AND METHODS: Transfusion medicine (TM) directors and pediatric trauma directors at 36 US children's hospitals were surveyed by e-mail in June 2020. Hospitals were selected by participation in the Massive Transfusion Epidemiology and Outcomes in Children Study or being among the largest 30 children's hospitals by bed capacity per the Becker Hospital Review. RESULTS: The response rate was 83.3% (30/36) from TM directors and 88.9% (32/36) from trauma directors. The median of massive transfusion protocol activations for traumatic bleeding was reported as 12 (IQR 5.8-20) per year by TM directors. LTOWB was used by 18.8% (6/32) of trauma directors. Survey responses indicate that 86.7% (26/30) of TM directors and 90.6% (29/32) of trauma directors either moderately or strongly agree that a LTOWB RCT is important to perform. About 83.3% (25/30) of TM directors and 93.8% (30/32) of trauma directors were willing to participate in the proposed trial. About 80% (24/30) of TM directors and 71.9% (23/32) of trauma directors would transfuse RhD+ LTOWB to male children, but fewer would transfuse Rh + LTOWB to females [20% (6/30) TM directors and 37.5% (12/32) of trauma directors]. CONCLUSIONS: A majority of respondents supported an RCT comparing LTOWB to component therapy in children with severe traumatic bleeding.


Assuntos
Sistema ABO de Grupos Sanguíneos/sangue , Transfusão de Componentes Sanguíneos , Hemorragia/terapia , Ferimentos e Lesões/terapia , Transfusão de Componentes Sanguíneos/métodos , Criança , Pré-Escolar , Feminino , Hemorragia/sangue , Humanos , Lactente , Masculino , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Ressuscitação/métodos , Inquéritos e Questionários , Ferimentos e Lesões/sangue
10.
Transfusion ; 61 Suppl 1: S49-S57, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269460

RESUMO

BACKGROUND: Coagulopathic bleeding is frequently present after major trauma. However, trauma-induced coagulopathy (TIC) remains incompletely understood. This laboratory analysis of blood samples derived from our completed trial on fibrinogen in the initial resuscitation of severe trauma (FiiRST) was conducted to evaluate TIC and associated responses to fibrinogen replacement. STUDY DESIGN AND METHODS: We conducted a retrospective evaluation of TIC in 45 FiiRST trial patients based on rotational thromboelastometry (ROTEM), international normalized ratio (INR), and biomarkers for hemostasis and endotheliopathy. Whole blood was analyzed by ROTEM. Plasma was analyzed for INR and biomarkers. RESULTS: Overall, 19.0% and 30.0% of the FiiRST trial patients were coagulopathic on admission defined by EXTEM maximum clot firmness out of the range of 40-71 mm and INR >1.2, respectively. The FiiRST patients showed lower fibrinogen, factor II and V levels, protein C and antiplasmin activities, higher activated protein C, tissue plasminogen activator, d-dimer, and thrombomodulin concentrations at admission than healthy controls. Most of the biomarkers changed their activities during 48-h hospitalization, but were at abnormal levels even 48-h after admission. The fibrinogen treatment reduced hypofibrinogenemia and increased factor XIII level, but had no significant effects on other biomarkers levels. Limited development of endotheliopathy was indicated by syndean-1, thrombomodulin, and sE-selectin. CONCLUSIONS: About 19%-30% of the trauma patients in the FiiRST trial were coagulopathic on hospital admission depending on the definition of TIC. Analyses of the TIC biomarkers demonstrated that hemostasis would not return to normal after 48-h hospitalization, and fibrinogen replacement improved hypofibrinogenemia.


Assuntos
Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/terapia , Fibrinogênio/uso terapêutico , Ressuscitação/métodos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Adulto , Transtornos da Coagulação Sanguínea/sangue , Feminino , Fibrinogênio/análise , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Tromboelastografia , Ferimentos e Lesões/sangue , Adulto Jovem
11.
Transfusion ; 61 Suppl 1: S15-S21, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269467

RESUMO

BACKGROUND: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion. STUDY DESIGN AND METHODS: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed. RESULTS: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05). DISCUSSION: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.


Assuntos
Transfusão de Sangue , Ressuscitação , Choque Hemorrágico/terapia , Adulto , Transfusão de Sangue/métodos , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Ressuscitação/métodos , Choque Hemorrágico/sangue , Choque Hemorrágico/mortalidade , Adulto Jovem
13.
Methods Mol Biol ; 2321: 121-135, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34048012

RESUMO

The translation of preclinical results into successful clinical therapies remains a challenge in sepsis research. One reason for this lack of translation might be the discrepancy between preclinical models and the clinical reality: nonresuscitated young healthy rodents in contrast to elderly comorbid patients in an intensive care unit. We introduce the mouse intensive care unit (MICU) as a concept to address the lack of resuscitation in preclinical studies as one of the limiting issues in translational research. The MICU reflects standard procedures of the clinical intensive care unit: fluid resuscitation, lung-protective mechanical ventilation, and hemodynamic monitoring and management, all tailored to organ- and function-specific targets. Thus, the MICU gives an experimental animal the intermediate possibility of recovery and survival due to "patient" management, which is not reflected in less complex experimental scenarios, which either result in acute survival or death.


Assuntos
Estudos Clínicos como Assunto/métodos , Camundongos/fisiologia , Animais , Hemodinâmica/fisiologia , Unidades de Terapia Intensiva , Pulmão/fisiopatologia , Respiração Artificial/métodos , Ressuscitação/métodos , Sepse/fisiopatologia , Pesquisa Médica Translacional/métodos
14.
Pediatr Pulmonol ; 56(7): 2057-2066, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33826802

RESUMO

BACKGROUND: Aerosol generating medical procedures (AGMPs) are common during newborn resuscitation. Neonates with respiratory viruses such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may pose a risk to healthcare workers. International guidelines differ on methods to minimize the risk due to limited data. OBJECTIVE: We examined the expiratory airflow dispersion during common neonatal resuscitation AGMPs using infant simulators. METHODS: Expiratory airflow dispersion in term and preterm manikins was simulated (n = 288) using fine particle smoke at tidal volumes of 5 ml/kg. Using ImageJ, we quantified dispersion during common airway procedures including endotracheal tube (ETT) and T-piece ventilation. RESULTS: Maximal expiratory dispersion distances for the unsupported airway and disconnected uncuffed ETT scenarios were 30.2 and 22.7 cm (term); 22.1 and 17.2 cm (preterm), respectively. Applying T-piece positive end expiratory pressure (PEEP) via an ETT (ETTPEEP ) generated no expiratory dispersion but increased tube leak during term simulation, while ventilation breaths (ETTVENT ) caused significant expiratory dispersion and leak. There was no measurable dispersion during face mask ventilation. For term uncuffed ETT ventilation, the particle filter eliminated expiratory dispersion but increased leak. No expiratory dispersion and negligible leak were observed when combining a cuffed ETT and filter. Angulated T-pieces generated the greatest median dispersion distances of 35.8 cm (ETTPEEP ) and 23.3 cm (ETTVENT ). CONCLUSIONS: Airflow dispersion during neonatal AGMPs is greater than previously postulated and potentially could contaminate healthcare providers during resuscitation of infants infected with contagious viruses such as SARS-CoV-2. It is possible to mitigate this risk using particle filters and cuffed ETTs. Applicability in the clinical setting requires further evaluation.


Assuntos
Microbiologia do Ar , Expiração , Vírus Sinciciais Respiratórios/isolamento & purificação , Ressuscitação/métodos , SARS-CoV-2/isolamento & purificação , Simulação por Computador , Humanos , Recém-Nascido , Intubação Intratraqueal , Manequins , Respiração com Pressão Positiva/métodos , Pressão , Volume de Ventilação Pulmonar
15.
Transfusion ; 61(6): 1757-1763, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33797100

RESUMO

BACKGROUND: Recently revisited products like low-titer group O whole blood (LTOWB) and novel applications of group A as a universal donor of plasma are being used for trauma resuscitation. A survey of American Level 1 trauma centers was performed to elucidate the extent to which these products are currently employed. METHODS: A survey was written that probed into the current use of blood products in trauma resuscitation with specific emphasis on LTOWB and group A plasma. A list of adult civilian Level 1 trauma centers in the continental USA was obtained from two public surgery and trauma focused websites. An email was then sent to each center's transfusion service medical director or laboratory manager providing them with a link to the online survey. RESULTS: Responses were received from 103/187 (55%) adult civilian Level 1 trauma centers. For the resuscitation of trauma patients, group A plasma was used at 94/103 (91%) centers, while LTOWB was used at 43/103 (42%) centers. There were 39/103 (38%) centers that used both products. At 62/94 (66%) of the centers that used group A plasma, there was no limit on the number of units that could be administered, while an unlimited number of LTOWB units could be used at 5/43 (12%) of the centers that used LTOWB. RhD-positive LTOWB could be transfused to RhD-negative or RhD-type unknown females of childbearing potential at 22/43 (51%) of centers. CONCLUSION: The use of group A plasma and LTOWB in trauma is increasing at American Level 1 trauma centers.


Assuntos
Transfusão de Sangue , Ressuscitação , Ferimentos e Lesões/terapia , Sistema ABO de Grupos Sanguíneos/sangue , Adulto , Transfusão de Sangue/métodos , Feminino , Humanos , Masculino , Ressuscitação/métodos , Inquéritos e Questionários , Centros de Traumatologia , Ferimentos e Lesões/sangue
16.
Transfusion ; 61(6): 1710-1720, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33811640

RESUMO

INTRODUCTION: Low-titer group O whole blood (LTOWB) is being increasingly transfused to injured patients. This study evaluated a range of clinical outcomes to determine if receipt of LTOWB predisposed recipients to worse outcomes compared to recipients of conventional component therapy (CCT). METHODS: A retrospective analysis of trauma patients who received at least 3 units of LTOWB (LTOWB group) versus those that received at least 3 units of RBCs, 1 unit of plasma and 1 unit of platelets but no LTOWB (CCT group) during the first 24 h of their admission was performed. Causal treatment effects were explored using propensity score matching (PSM) and coarsened exact matching (CEM). Important clinical outcomes were evaluated. RESULTS: There were 165 CCT and 155 LTOWB recipients eligible for matching. PSM and CEM reduced covariate imbalances between the CCT and LTOWB groups, with the exception that males remained over-represented in the LTOWB group due to the hospital's former resuscitation policy of not administering RhD-positive LTOWB to females <50. In both of the matched analyses, the LTOWB group received a median of 4 LTOWB units. There were no significant differences in 6-, 24-h mortality or 30-day mortality between groups, nor were there differences in the frequency of other clinical outcomes such as acute kidney injury, sepsis, venous/arterial thromboembolism; delta MODS was lower for the LTOWB recipients in the exact match group. CONCLUSION: In both matched analyses, administration of a median of four LTOWB units did not result in a different frequency of major clinical outcomes including mortality.


Assuntos
Transfusão de Sangue , Ferimentos e Lesões/terapia , Sistema ABO de Grupos Sanguíneos/sangue , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ressuscitação/métodos , Estudos Retrospectivos , Ferimentos e Lesões/sangue , Adulto Jovem
17.
Am J Physiol Lung Cell Mol Physiol ; 320(6): L1126-L1136, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33826416

RESUMO

Intravenous fluids are widely used to treat circulatory deterioration in pediatric acute respiratory distress syndrome (PARDS). However, the accumulation of fluids in the first days of PARDS is associated with adverse outcome. As such, early fluid restriction may prove beneficial, yet the effects of such a fluid strategy on the cardiopulmonary physiology in PARDS are unclear. In this study, we compared the effect of a restrictive with a liberal fluid strategy on a hemodynamic response and the formation of pulmonary edema in an animal model of PARDS. Sixteen mechanically ventilated lambs (2-6 wk) received oleic acid infusion to induce PARDS and were randomized to a restrictive or liberal fluid strategy during a 6-h period of mechanical ventilation. Transpulmonary thermodilution determined extravascular lung water (EVLW) and cardiac output (CO). Postmortem lung wet-to-dry weight ratios were obtained by gravimetry. Restricting fluids significantly reduced fluid intake but increased the use of vasopressors among animals with PARDS. Arterial blood pressure was similar between groups, yet CO declined significantly in animals receiving restrictive fluids (P = 0.005). There was no difference in EVLW over time (P = 0.111) and lung wet-to-dry weight ratio [6.1, interquartile range (IQR) = 6.0-7.3 vs. 7.1, IQR = 6.6-9.4, restrictive vs. liberal, P = 0.725] between fluid strategies. Both fluid strategies stabilized blood pressure in this model, yet early fluid restriction abated CO. Early fluid restriction did not limit the formation of pulmonary edema; therefore, this study suggests that in the early phase of PARDS, a restrictive fluid strategy is not beneficial in terms of immediate cardiopulmonary effects.


Assuntos
Água Extravascular Pulmonar/metabolismo , Hidratação , Hemodinâmica/fisiologia , Síndrome do Desconforto Respiratório/terapia , Animais , Água Extravascular Pulmonar/fisiologia , Hidratação/métodos , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/metabolismo , Ressuscitação/métodos , Ovinos , Fatores de Tempo
18.
West J Emerg Med ; 22(2): 369-378, 2021 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-33856325

RESUMO

INTRODUCTION: The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy. METHODS: This was a randomized controlled trial conducted in an urban, university-affiliated tertiary-care hospital. Adult patients with SITH/SS were randomized to receive treatment with UGFM using respiratory change of the IVC (UGFM strategy) or with the usual-care strategy during the first six hours after emergency department (ED) arrival. We compared the 30-day mortality rate and other clinical outcomes between the two groups. RESULTS: A total of 202 patients were enrolled, 101 in each group (UGFM vs usual-care strategy) for intention-to-treat analysis. There was no significant difference in 30-day overall mortality between the two groups (18.8% and 19.8% in the usual-care and UGFM strategy, respectively; p > 0.05 by log rank test). Neither was there a difference in six-hour lactate clearance, a change in the sequential organ failure assessment score, or length of hospital stay. However, the cumulative fluid amount given in 24 hours was significantly lower in the UGFM arm. CONCLUSION: In our ED setting, the use of respiratory change of IVC diameter determined by point-of-care ultrasound to guide initial fluid resuscitation in SITH/SS ED patients did not improve the 30-day survival probability or other clinical parameters compared to the usual-care strategy. However, the IVC ultrasound-guided resuscitation was associated with less amount of fluid used.


Assuntos
Hidratação , Ressuscitação , Choque Séptico , Ultrassonografia de Intervenção/métodos , Veia Cava Inferior , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hidratação/instrumentação , Hidratação/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Tamanho do Órgão , Avaliação de Processos e Resultados em Cuidados de Saúde , Ressuscitação/instrumentação , Ressuscitação/métodos , Choque Séptico/etiologia , Choque Séptico/mortalidade , Choque Séptico/terapia , Análise de Sobrevida , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/patologia
19.
Am J Surg ; 221(6): 1233-1237, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33838867

RESUMO

INTRODUCTION: To analyze our experience to quantify potential need for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS: Retrospective review of patients over a three-year period who presented as a trauma with hemorrhagic shock. Patients were divided into two groups: REBOA Candidate vs. Non-candidates. Injuries, outcomes, and interventions were compared. RESULTS: Of 7643 trauma activations, only 37 (0.44%) fit inclusion criteria, of which 16 met criteria for candidacy for potential REBOA placement. The groups did not differ in terms of injury severity, physiology, age, timing of intervention, nor massive transfusion. Survival was linked to TRISS (p = 0.01) and Emergency Room Thoracotomy (p = 0.002). Of Candidates, 8 (50%) had injuries that could have benefited from REBOA, while 7 (44%) had injuries that could be associated with potential harm. DISCUSSION: The volume of patients who would potentially benefit from REBOA appears to be small and does not appear to support system wide adoption in the studied region. LEVEL OF EVIDENCE: IV.


Assuntos
Aorta , Oclusão com Balão/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/terapia , Adulto , Oclusão com Balão/mortalidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Ressuscitação/mortalidade , Estudos Retrospectivos , Choque Hemorrágico/mortalidade , Traumatismos Torácicos/mortalidade , Traumatismos Torácicos/terapia , Toracotomia , Resultado do Tratamento , Ferimentos e Lesões/mortalidade
20.
Emerg Med Clin North Am ; 39(2): 273-286, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33863459

RESUMO

In 30 years, adults 65 and older will represent 20% of the US population, with increased medical comorbidities leading to higher rates of critical illness and mortality. Despite significant acute illness, presenting symptoms and vital sign abnormalities may be subtle. Resuscitative guidelines are a helpful starting point but appropriate diagnostics, bedside ultrasound, and frequent reassessments are needed to avoid procrustean care that may worsen outcomes. Baseline functional status is as important as underlying comorbid conditions when prognosticating, and the patient's personal wishes should be sought early and throughout care with clear communication regarding prospects for immediate survival and overall recovery.


Assuntos
Estado Terminal/terapia , Ressuscitação/métodos , Diretivas Antecipadas , Idoso , Envelhecimento/fisiologia , Doenças Cardiovasculares/fisiopatologia , Humanos , Nefropatias/fisiopatologia , Pneumopatias/fisiopatologia , Sistemas Automatizados de Assistência Junto ao Leito , Insuficiência Respiratória/terapia , Choque/diagnóstico , Choque/terapia , Ultrassonografia
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