RESUMEN
Uncontrolled hemorrhage stands as the primary cause of potentially preventable deaths following traumatic injuries in both civilian and military populations. Addressing this critical medical need requires the development of a hemostatic material with rapid hemostatic performance and biosafety. This work describes the engineering of a chitosan-based cryogel construct using thermo-assisted cross-linking with α-ketoglutaric acid after freeze-drying. The resulting cryogel exhibited a highly interconnected macro-porous structure with low thermal conductivity, exceptional mechanical properties, and great fluid absorption capacity. Notably, assessments using rabbit whole blood in vitro, as well as rat liver volume defect and femoral artery injury models simulating severe bleeding, showed the remarkable hemostatic performance of the chitosan cryogel. Among the cryogel variants with different chitosan molecular weights, the 150 kDa one demonstrated superior hemostatic efficacy, reducing blood loss and hemostasis time by approximately 73 % and 63 % in the hepatic model, and by around 60 % and 68 %, in the femoral artery model. Additionally, comprehensive in vitro and in vivo evaluations underscored the good biocompatibility of the chitosan cryogel. Taken together, these results strongly indicate that the designed chitosan cryogel configuration holds significant potential as a safe and rapid hemostatic material for managing severe hemorrhage.
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Quitosano , Criogeles , Hemorragia , Hemostáticos , Quitosano/química , Quitosano/farmacología , Criogeles/química , Animales , Conejos , Hemorragia/terapia , Hemorragia/tratamiento farmacológico , Hemostáticos/química , Hemostáticos/farmacología , Ratas , Masculino , Ratas Sprague-Dawley , Arteria Femoral/lesiones , Porosidad , Hígado/efectos de los fármacos , Materiales Biocompatibles/química , Materiales Biocompatibles/farmacología , Reactivos de Enlaces Cruzados/química , Hemostasis/efectos de los fármacosRESUMEN
Background: The most common cause of preventable death after injury is haemorrhage. Resuscitative endovascular balloon occlusion of the aorta is intended to provide earlier, temporary haemorrhage control, to facilitate transfer to an operating theatre or interventional radiology suite for definitive haemostasis. Objective: To compare standard care plus resuscitative endovascular balloon occlusion of the aorta versus standard care in patients with exsanguinating haemorrhage in the emergency department. Design: Pragmatic, multicentre, Bayesian, group-sequential, registry-enabled, open-label, parallel-group randomised controlled trial to determine the clinical and cost-effectiveness of standard care plus resuscitative endovascular balloon occlusion of the aorta, compared to standard care alone. Setting: United Kingdom Major Trauma Centres. Participants: Trauma patients aged 16 years or older with confirmed or suspected life-threatening torso haemorrhage deemed amenable to adjunctive treatment with resuscitative endovascular balloon occlusion of the aorta. Interventions: Participants were randomly assigned 1 : 1 to: standard care, as expected in a major trauma centre standard care plus resuscitative endovascular balloon occlusion of the aorta. Main outcome measures: Primary: Mortality at 90 days. Secondary: Mortality at 6 months, while in hospital, and within 24, 6 and 3 hours; need for haemorrhage control procedures, time to commencement of haemorrhage procedure, complications, length of stay (hospital and intensive care unit-free days), blood product use. Health economic: Expected United Kingdom National Health Service perspective costs, life-years and quality-adjusted life-years, modelled over a lifetime horizon. Data sources: Case report forms, Trauma Audit and Research Network registry, NHS Digital (Hospital Episode Statistics and Office of National Statistics data). Results: Ninety patients were enrolled: 46 were randomised to standard care plus resuscitative endovascular balloon occlusion of the aorta and 44 to standard care. Mortality at 90 days was higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group (54%) compared to the standard care group (42%). The odds ratio was 1.58 (95% credible interval 0.72 to 3.52). The posterior probability of an odds ratio > 1 (indicating increased odds of death with resuscitative endovascular balloon occlusion of the aorta) was 86.9%. The overall effect did not change when an enthusiastic prior was used or when the estimate was adjusted for baseline characteristics. For the secondary outcomes (3, 6 and 24 hours mortality), the posterior probability that standard care plus resuscitative endovascular balloon occlusion of the aorta was harmful was higher than for the primary outcome. Additional analyses to account for intercurrent events did not change the direction of the estimate for mortality at any time point. Death due to haemorrhage was more common in the standard care plus resuscitative endovascular balloon occlusion of the aorta group than in the standard care group. There were no serious adverse device effects. Resuscitative endovascular balloon occlusion of the aorta is less costly (probability 99%), due to the competing mortality risk but also substantially less effective in terms of lifetime quality-adjusted life-years (probability 91%). Limitations: The size of the study reflects the relative infrequency of exsanguinating traumatic haemorrhage in the United Kingdom. There were some baseline imbalances between groups, but adjusted analyses had little effect on the estimates. Conclusions: This is the first randomised trial of the addition of resuscitative endovascular balloon occlusion of the aorta to standard care in the management of exsanguinating haemorrhage. All the analyses suggest that a strategy of standard care plus resuscitative endovascular balloon occlusion of the aorta is potentially harmful. Future work: The role (if any) of resuscitative endovascular balloon occlusion of the aorta in the pre-hospital setting remains unclear. Further research to clarify its potential (or not) may be required. Trial registration: This trial is registered as ISRCTN16184981. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/199/09) and is published in full in Health Technology Assessment; Vol. 28, No. 54. See the NIHR Funding and Awards website for further award information.
Trauma (physical injury) is a major cause of death and disability. The most common cause of preventable death after injury is uncontrolled bleeding. Resuscitative endovascular balloon occlusion of the aorta is a technique whereby a small balloon is inflated in the aorta (main blood vessel) which aims to limit blood loss until an operation can be done to stop the bleeding. In this study, which is the first randomised trial in the world of this technique, we investigated whether adding resuscitative endovascular balloon occlusion of the aorta to the standard care received in a major trauma centre reduced the risk of death in trauma patients who had life-threatening uncontrolled bleeding. The study took place in 16 major trauma centres in the United Kingdom. Ninety adult trauma patients with confirmed or suspected uncontrolled bleeding took part and were randomly divided into two groups: (1) those who received standard care and (2) those who received standard care plus resuscitative endovascular balloon occlusion of the aorta. We followed participants for 6 months using routinely collected data from the National Health Service and from the Trauma Audit Research Network registry. We also contacted surviving patients at 6 months to ask about their quality of life. In the standard care group, 42% of participants died within 90 days of their injury compared to 54% of participants in the standard care plus resuscitative endovascular balloon occlusion of the aorta group. Risk of death was also higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group at all other time points (3, 6 and 24 hours, in hospital and at 6 months). Overall, the study showed that the use of resuscitative endovascular balloon occlusion of the aorta in hospital increased the risk of death.
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Oclusión con Balón , Análisis Costo-Beneficio , Procedimientos Endovasculares , Resucitación , Humanos , Oclusión con Balón/métodos , Femenino , Masculino , Reino Unido , Adulto , Persona de Mediana Edad , Resucitación/métodos , Procedimientos Endovasculares/métodos , Hemorragia/terapia , Aorta , Teorema de Bayes , Torso , Años de Vida Ajustados por Calidad de Vida , Heridas y Lesiones/terapia , Heridas y Lesiones/complicaciones , Anciano , Centros TraumatológicosRESUMEN
BACKGROUND: Spontaneous hemopneumothorax is a rare condition that can be life-threatening if not promptly diagnosed and treated. We report a case of early treatment with transcatheter arterial embolization and video-assisted thoracoscopic surgery. CASE PRESENTATION: A 19-year-old Japanese male was diagnosed with left pneumothorax and underwent chest tube drainage. A total of 10 hours after admission, the patient developed dyspnea, chest pain, and sudden massive bloody effusion. Contrast-enhanced computed tomography revealed contrast extravasation near the left lung apex, and spontaneous hemopneumothorax was diagnosed. Angiography revealed bleeding from a branch of the subscapular artery and transcatheter arterial embolization was performed. The patient underwent video-assisted thoracoscopic surgery and recovered uneventfully. CONCLUSIONS: Anesthesiologists involved in urgent surgeries must be aware that a patient with spontaneous pneumothorax can develop a hemopneumothorax, even when full lung expansion has been obtained following chest tube drainage, owing to latent aberrant artery disruption. Interprofessional team engagement is essential for spontaneous hemopneumothorax management.
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Drenaje , Embolización Terapéutica , Hemoneumotórax , Cirugía Torácica Asistida por Video , Humanos , Masculino , Hemoneumotórax/terapia , Hemoneumotórax/diagnóstico por imagen , Hemoneumotórax/etiología , Adulto Joven , Tomografía Computarizada por Rayos X , Tubos Torácicos , Resultado del Tratamiento , Hemorragia/terapia , Hemorragia/etiología , Neumotórax/etiología , Neumotórax/terapia , Neumotórax/diagnóstico por imagen , AngiografíaRESUMEN
Patients with immune thrombocytopenia (ITP) admitted for non-ST elevation myocardial infarction (NSTEMI) present a unique therapeutic challenge due to the increased risk of bleeding with antiplatelet and anticoagulation therapies. There is limited evidence studying hospital mortality and complications in this population. The study included a patient cohort from the 2018-2021 National Inpatient Sample database. Propensity score matched NSTEMI patients with and without ITP using a 1:1 matching ratio. Outcomes analyzed were in-hospital mortality, rates of diagnostic angiogram, percutaneous coronary intervention (PCI), acute kidney injury (AKI), congestive heart failure (CHF), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, ventricular tachycardia (VT), ventricular fibrillation (VF), major bleeding, need for blood and platelet transfusion, length of stay (LOS), and total hospitalization charges. A total of 1,699,020 patients met inclusion criteria (660,490 females [39%], predominantly Caucasian 1,198,415 (70.5%); mean [SD] age 67, [3.1], including 2,615 (0.1%) patients with ITP. Following the propensity matching, 1,020 NSTEMI patients with and without ITP were matched. ITP patients had higher rates of inpatient mortality (aOR 1.98, 95% CI 1.11-3.50, p 0.02), cardiogenic shock, AKI, mechanical ventilation, tracheal intubation, red blood cells and platelet transfusions, longer LOS, and higher total hospitalization charges. The rates of diagnostic angiogram, PCI, CHF, VT, VF, and major bleeding were not different between the two groups. Patients with ITP demonstrated higher odds of in-hospital mortality for NSTEMI and need for platelet transfusion with no difference in rates of diagnostic angiogram or PCI.
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Mortalidad Hospitalaria , Infarto del Miocardio sin Elevación del ST , Intervención Coronaria Percutánea , Puntaje de Propensión , Púrpura Trombocitopénica Idiopática , Humanos , Femenino , Masculino , Anciano , Infarto del Miocardio sin Elevación del ST/terapia , Infarto del Miocardio sin Elevación del ST/mortalidad , Persona de Mediana Edad , Púrpura Trombocitopénica Idiopática/terapia , Púrpura Trombocitopénica Idiopática/complicaciones , Púrpura Trombocitopénica Idiopática/mortalidad , Púrpura Trombocitopénica Idiopática/diagnóstico , Púrpura Trombocitopénica Idiopática/epidemiología , Tiempo de Internación , Pacientes Internos , Anciano de 80 o más Años , Hemorragia/etiología , Hemorragia/mortalidad , Hemorragia/terapia , Lesión Renal Aguda/terapia , Lesión Renal Aguda/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: In hospitalized patients undergoing therapeutic plasma exchange (TPE), it is not known how TPE-associated bleeding risk is impacted by a prior bleeding episode. Therefore, to assess the prevalence and predictors of bleeding recurrence, we analyzed data from the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). MATERIALS AND METHODS: Using a retrospective cross-sectional analysis of REDS-III public use files, we identified hospitalized adults who had a major bleeding episode prior to their first TPE procedure. Patients were classified into two cohorts based on bleeding recurrence (no-recurrence vs recurrence). After identifying potential predictors, we used multiple imputation by chained equations to impute variables with <30% missing data. Variable selection was optimized using a 10-fold cross validated least absolute shrinkage and selection operator. Final predictors were identified by fitting a logistic regression model. RESULTS: In 310 patients with major bleeding prior to TPE initiation, bleeding recurred in 121 (39.0%). We identified the following seven unique predictors: 1) >10 TPE procedures (OR 2.23); 2) intensive care unit stay (OR 1.35); 3) thrombocytopenia (OR 1.26); 4) surgery (OR 1.22); 5) hepatic disease (OR 1.21); 6) 6-10 TPE procedures (OR 1.04); and 7) Asian race (OR 1.01). We also identified the following five interactions: 1) surgery and therapeutic anticoagulation (OR 1.50); 2) 6-10 TPE procedures and therapeutic anticoagulation (OR 1.05); 3) 6-10 TPE procedures and antiplatelets (OR 1.02); 4) >10 TPE procedures and antiplatelets (OR 1.00); and 5) albumin-only TPE and antiplatelets (OR 0.53). When assessed for adjusted performance, the prediction model had a C-statistic of 0.617 (95% CI 0.613-0.619) and Brier Score of 0.342 (95% CI 0.340-0.347). DISCUSSION: In this study assessing predictors of bleeding recurrence among hospitalized patients undergoing TPE, we identified seven variables and five interactions. These findings should be validated in future studies.
Asunto(s)
Hemorragia , Intercambio Plasmático , Recurrencia , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Hemorragia/terapia , Hemorragia/etiología , Hemorragia/epidemiología , Estudios Transversales , Anciano , Adulto , Factores de Riesgo , HospitalizaciónRESUMEN
OBJECTIVE: This study aimed to evaluate the prevalence of severe hemorrhage as a potentially life-threatening complication in elderly patients with isolated, low-energy pelvic ring fractures, which may be more common than previously described. PATIENTS AND METHODS: A retrospective cohort study was conducted at an academic level 1 trauma center, including 579 patients aged over 65 who suffered from isolated low-energy pelvic fractures between 2006 and 2020. Pelvic computer tomography (CT) scans, with or without contrast, were performed and reviewed for patients with suspected posterior ring injury or bleeding. Patients without CT scans were excluded from the study. RESULTS: Among the 123 patients with isolated pubic rami fractures, 30 (24.4 %) had bleeding with a significant hemoglobin drop (>2 g%). 21(70 %) patients of these had posterior pelvic ring involvement as compared to 45 who did not bleed (51 %, p = 0.07). There was a significantly larger proportion of patient who received anticoagulant therapy (ACT) with posterior ring injury among the bleeding group (20 % vs 3.2 % p < 0.01). Treatment included blood transfusion (19/123, 15.5 %), and arterial angiographic embolization (5/123, 4 %). No complications related to angio-embolization were observed, and all patients survived the initial 90-day period. No other source of bleeding was identified in any of these patients. CONCLUSION: Severe pelvic hemorrhage in the older adults due to a minor pelvic injury after a low-energy trauma is not an uncommon complication, especially with combination of ACT and posterior pelvic ring fracture. This indicates that these injuries more challenging than previously believed. Geriatric pelvic ring injuries should be monitored carefully with serial blood counts, and low threshold for imaging including contrast enhanced CT scans and angiography.
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Fracturas Óseas , Hemorragia , Huesos Pélvicos , Tomografía Computarizada por Rayos X , Humanos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Huesos Pélvicos/lesiones , Huesos Pélvicos/diagnóstico por imagen , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/complicaciones , Anciano de 80 o más Años , Hemorragia/etiología , Hemorragia/terapia , Centros Traumatológicos , Embolización Terapéutica , Transfusión Sanguínea/estadística & datos numéricosRESUMEN
OBJECTIVE: Increasingly, medical schools integrate clinical skills into early didactic coursework. The Stop the Bleed® Campaign emphasizes prehospital hemorrhage control to reduce preventable deaths; however, this course overlooks team interactions. We assessed the impact of high-fidelity simulation during medical student orientation on identification and treatment of life-threatening hemorrhage in a team setting. DESIGN: In this mixed method, prospective pre-, post-, and follow-up survey analysis assessing student knowledge and attitudes, student teams encountered a standardized patient in a prehospital environment with pulsatile bleeding from an extremity wound. Individual students completed surveys assessing previous experience, willingness and ability to assist bleeding person(s), and knowledge and attitudes about tourniquets. Postscenario, faculty preceptors made qualitative observations on teamwork. SETTING: Medical student orientation at a tertiary care academic medical center with long-term follow-up. PARTICIPANTS: Medical students (Nâ¯=â¯150). RESULTS: Ninety students (60%) completed both pre- and postsimulation questionnaires. Sixteen (17%) students had previous tourniquet training experience although none had applied a tourniquet outside of training. Postsimulation, students reported increased likelihood of providing treatment until additional help arrived (pâ¯=â¯0.035), improved ability to identify life-threatening hemorrhage (p < 0.001), and more favorable opinions about tourniquet use (p < 0.001) and potential for limb-salvage (pâ¯=â¯0.018). Long-term follow-up respondents (nâ¯=â¯34, 23%) reported increased ability to identify life-threatening hemorrhage (pâ¯=â¯0.010) and universal willingness to intervene until additional help arrived. Follow-up survey responses elicited themes in hemorrhage control including recognition of the importance of continuous pressure, appropriate use of tourniquets, a desire for repeated team training, and the recognition of clerkship rotations as an optimal setting for skill reinforcement. Preceptors noted variable team responses but uniformly endorsed the exercise. CONCLUSIONS: High-fidelity bleeding simulation during medical student orientation improved students' knowledge and attitudes about treating life-threatening hemorrhage and served as an introduction to team-based emergency care. Future studies should further explore team training and hemorrhage control education.
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Competencia Clínica , Educación de Pregrado en Medicina , Hemorragia , Humanos , Hemorragia/terapia , Hemorragia/prevención & control , Estudios Prospectivos , Educación de Pregrado en Medicina/métodos , Femenino , Masculino , Estudios de Seguimiento , Autoinforme , Torniquetes , Enseñanza Mediante Simulación de Alta Fidelidad/métodos , Estudiantes de MedicinaRESUMEN
INTRODUCTION: Battlefield trauma necessitates prompt hemostatic intervention to mitigate fatalities resulting from critical blood loss. Insights from Operation Enduring Freedom and Operation Iraqi Freedom emphasize the limitations of conventional methods, such as tourniquets, especially in noncompressible torso hemorrhage. Despite advancements in hemostatic agents, the evolving dynamics of multidomain operations necessitate novel, lightweight strategies for hemorrhage control. This study investigates the Silicone-Based Polymer (SBP) Universal Combat Matrix (UCM) by SiOxMed, a multimodal matrix exhibiting efficacy in lethal hemorrhage models. The study evaluates UCM's multiday hemostatic capabilities in a noncompressible torso hemorrhage model, offering pivotal insights for potential deployment in battlefield trauma. MATERIALS AND METHODS: This research was performed under Institutional Animal Care and Use Committee approval and was designed to replicate austere conditions in an off-site enclosed facility. Yorkshire Hampshire swine underwent baseline assessments and anesthesia induction (n = 3). A Grade IV liver injury was made by incising X-shaped lesions, each measuring 4 cm × 2.5 cm, into the diaphragmatic surface of the left and right middle lobes using a scalpel blade, resulting in a lesion region of approximately 3 cm × 6 cm × 3 cm, followed by 30 seconds of uncontrolled bleeding. The injuries were then treated with SBP. Intensive care unit monitoring for 1 hour ensured sustained hemostasis, followed by 48 hours of postanesthesia monitoring and then a return to the operating table to visualize sustained hemostasis. Posteuthanasia, liver tissue underwent histological assessments to evaluate the hemorrhagic interface and liver tissue reactivity. RESULTS: The average time to hemostatic control was 247.3 ± 71.3 seconds. Stable heart rate (81.3 ± 10.0) and respiratory rate (31.7 ± 16.5) were maintained during intensive care unit monitoring. All swine survived the 1-hour anesthesia monitoring period and the subsequent 48-hour monitoring (average survival time, 48.0 hours ± 0.0, n = 3). Visualization of the abdominal cavity at 48 hours revealed no hemorrhage. Histological assessment demonstrated aligned red blood cells and stratified layers of fibrin at the hemorrhagic interface. Masson's Trichrome analysis demonstrated a reactive and regenerative scenario 48 hours postinjury, with a collagen membrane demarcating uninjured and exposed liver regions, along with a comprehensive stromal response. CONCLUSIONS: In conclusion, our investigation into the SBP UCM hemostatic efficacy in a grade IV liver laceration model demonstrates its rapid and reliable action in controlling bleeding, showcasing practicality with an average mass of 4.0 ± 1.0 g. Silicone-Based Polymer sustained hemostasis without adverse physiological effects, as evidenced by stable parameters and the survival of all swine during and after anesthesia. Macroscopic examination at 48 hours revealed durable adherence with no indications of hemorrhage. Histological evaluations highlighted SBP's role in stable clot formation, fibrinogenesis, and tissue regeneration, indicating its potential as a multimodal wound dressing. Although promising, the study has limitations, emphasizing the need for future research with larger samples and controls. This work sets the stage for exploring SBP's clinical implications, particularly in scenarios where lightweight, multimodal technologies are crucial for addressing traumatic injuries and enhancing military medical capabilities.
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Hemorragia , Animales , Porcinos , Hemorragia/terapia , Hemorragia/etiología , Siliconas/uso terapéutico , Siliconas/farmacología , Modelos Animales de Enfermedad , Polímeros/uso terapéutico , Torso/lesionesRESUMEN
INTRODUCTION: Retrograde Endovascular Balloon Occlusion of the Aorta (REBOA) is an effective management for the transient responder, but the ischemic consequences of complete aortic occlusion currently limit its use. Multiple DoD-funded preclinical studies have clearly demonstrated that partial REBOA reduces distal ischemia to potentially extend safe occlusion times, while still providing effective temporization of noncompressible torso hemorrhage. Early versions of REBOA devices were designed to completely occlude the aorta and had little ability to provide partial occlusion. Recently, a new REBOA device (pREBOA-PRO) was designed specifically to allow for partial occlusion, with the hypothesis that this may reduce the complications of aortic occlusion and extend safe occlusion times while maintaining the benefits on cardiac and cerebrovascular circulation as well as reductions in resuscitation requirements. MATERIALS AND METHODS: To ascertain the impact of a new purpose-built partial REBOA device on the extension of safe occlusion time, the Partial REBOA Outcomes Multicenter ProspecTive (PROMPT) trial compared available data from the pREBOA-PRO with existing data from 200 clinical uses of pREBOA-PRO and available data in the AAST AORTA Registry were reviewed to design primary endpoints and clinical evidence for a prospective multi-center trial, the PROMPT Study. Together with the endpoints identified in preclinical studies of partial REBOA, primary endpoints for the PROMPT study were identified and power analyses were conducted to determine the target patient enrollment goals. RESULTS: Results from the clinical implementation of partial REBOA at a single trauma center were used to conduct the initial power analysis for the primary endpoint of Acute Kidney Injury (AKI) after prolonged occlusion. The rate of AKI after complete REBOA was 55% (12/20) compared to 33% (4/12) after partial REBOA (Madurska et al., 2021). With an alpha of 0.05 and power (ß) of 0.8, the projected sample size for comparison on a dichotomous outcome is 85 patients for the assessment of AKI. Initial power and endpoint analyses have been confirmed and extended with the ongoing analysis of partial and complete REBOA reported in the AORTA database. These analyses confirm preclinical findings which show that compared to complete REBOA, partial REBOA is associated with extended occlusion time in zone 1 (complete: 31 min vs. partial: 45 min, P = 0.003), lower rates of AKI after zone 1 occlusion (complete: 33% vs. partial: 19%, P = 0.05) and reduced resuscitation requirements (e.g., 25% reduction in pRBC administration: complete: 18 units vs. partial: 13 units, P = 0.02). CONCLUSIONS: The DoD-funded PROMPT study of partial REBOA will provide prospective observational clinical data on patients being treated with pREBOA-PRO. Outcomes will be stratified based on partial or complete occlusion to address whether partial REBOA has additional clinical benefits over complete REBOA, such as decreased distal ischemia, extension of safe occlusion time, improved hemodynamics during transition to and from occlusion, and reduced interoperative bleeding and blood product use. The results from this study are expected to confirm previous data demonstrating reduction of ischemic sequalae, improved transition to reperfusion, and reduced resuscitative requirements compared to complete REBOA.
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Aorta , Oclusión con Balón , Humanos , Oclusión con Balón/métodos , Oclusión con Balón/normas , Oclusión con Balón/instrumentación , Oclusión con Balón/estadística & datos numéricos , Estudios Prospectivos , Masculino , Femenino , Adulto , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/instrumentación , Persona de Mediana Edad , Resucitación/métodos , Resucitación/instrumentación , Resucitación/normas , Resucitación/estadística & datos numéricos , Hemorragia/terapia , Hemorragia/prevención & control , Resultado del TratamientoRESUMEN
Patients with liver cirrhosis often exhibit complex alterations in their hemostatic system that can be associated with both bleeding and thrombotic complications. While prophylactic correction of abnormal coagulation parameters should be avoided, an individualized approach is recommended prior to invasive procedures, whereby specific preventive measures to stabilize hemostasis should be based on the periprocedural bleeding risk. While the haemostatic system of patients with compensated cirrhosis is often in a rebalanced haemostatic state due to a parallel decline in both pro- and anti-haemostatic factors, a decompensation of liver cirrhosis can lead to destabilization of this fragile equilibrium. Since conventional coagulation tests do not adequately capture the complex changes in the hemostatic system in cirrhosis, functional analysis methods such as viscoelastic tests or thrombin generation assays can be used for evaluating the coagulation status. This review describes the underlying pathophysiological changes in the hemostatic system in liver cirrhosis, provides an overview of diagnostic methods and discusses therapeutic measures in case of bleeding and thrombotic complications.
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Trastornos de la Coagulación Sanguínea , Cirrosis Hepática , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Trastornos de la Coagulación Sanguínea/diagnóstico , Trastornos de la Coagulación Sanguínea/terapia , Trastornos de la Coagulación Sanguínea/etiología , Pruebas de Coagulación Sanguínea , Hemorragia/etiología , Hemorragia/terapia , Hemorragia/diagnóstico , Trombosis/diagnóstico , Trombosis/etiología , Trombosis/terapia , Trombosis/prevención & controlRESUMEN
INTRODUCTION: Preperitoneal pelvic packing (PPP) has been advocated as a damage control procedure for pelvic fracture bleeding, despite of weak evidence. METHODS: Matched cohort study, TQIP database. Patients with isolated severe blunt pelvic fractures (pelvis abbreviated injury score [AIS] â≥ â3, AIS ≤2 in all other body regions) were included. Patients who underwent PPP were matched to patients with no PPP, 1:3 nearest propensity score. Matching was performed based on demographics, vital signs on admission, comorbidities, injury characteristics, type and timing of initiation of VTE prophylaxis, and additional procedures including laparotomy, REBOA, and angioembolization. RESULTS: 64 patients with PPP were matched with 182 patients with No-PPP. PPP patients had higher in-hospital mortality (14.1 â% vs 2.2 â% p â< â0.001) and higher rates of VTE and DVT (VTE: 14.1 â% vs 4.4 â% p â= â0.018, DVT: 10.9 â% vs 2.2 â% p â= â0.008). CONCLUSION: PPP is associated with worse survival outcomes and increased rate of VTE and DVT complications.
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Fracturas Óseas , Huesos Pélvicos , Puntaje de Propensión , Tromboembolia Venosa , Humanos , Femenino , Masculino , Huesos Pélvicos/lesiones , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/etiología , Tromboembolia Venosa/epidemiología , Fracturas Óseas/mortalidad , Fracturas Óseas/complicaciones , Fracturas Óseas/cirugía , Persona de Mediana Edad , Adulto , Mortalidad Hospitalaria , Estudios Retrospectivos , Técnicas Hemostáticas , Heridas no Penetrantes/mortalidad , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/terapia , Estudios de Cohortes , Anciano , Hemorragia/mortalidad , Hemorragia/etiología , Hemorragia/terapia , Puntaje de Gravedad del TraumatismoRESUMEN
BACKGROUND: The trans femoral ipsilateral approach is often adopted for endovascular treatment (EVT) for better steerability of guidewires or better device deliverability. However, contrary to the trans femoral contralateral approach, ipsilateral antegrade puncture sometimes causes peculiar bleeding complications. CASE PRESENTATION: A 76-year-old female underwent EVT for chronic occlusion of the left superficial femoral artery (SFA) via the ipsilateral antegrade approach. After guidewire passage, we inflated the drug-coated balloons, but angiography showed blood flow stasis at the mid segment of the SFA. We also ensured prolonged balloon inflation, which resulted in favorable blood flow. While trying to ensure hemostasis, the blood pressure remained decreased, but neither bleeding nor superficial hematoma were observed at the puncture site. After hemostasis was achieved, we removed the surgical drape and noticed a swelling in the mid-portion of the thigh, distant from the puncture point. We then approached the left common femoral artery (CFA) contralaterally. Angiography showed continuous bleeding from a little bit distally to the sheath insertion point that was spreading through an intramuscular space. We stopped the bleeding with balloon tamponade inside the CFA. Angiography after hemostasis demonstrated blood flow stasis at the mid-segment of the SFA, similarly as that seen before. We confirmed compression of the SFA by a large hematoma using both intra- and extra- vascular ultrasound. Therefore, we deployed a self-expandable stent at the compressed SFA position. Finally, we achieved favorable blood flow on angiography. CONCLUSION: We encountered a case that latent bleeding unrecognized in the surgical field persisted while prolonged inflation of DCB was conducted at just proximal SFA. We could have avoided bailout stenting by noticing the bleeding incident in a timely manner. Prediction and prevention are essential for all kinds of procedural complications in EVT.
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Diagnóstico Tardío , Arteria Femoral , Hemorragia , Punciones , Humanos , Femenino , Anciano , Arteria Femoral/diagnóstico por imagen , Hemorragia/etiología , Hemorragia/terapia , Resultado del Tratamiento , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Valor Predictivo de las Pruebas , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/instrumentación , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Técnicas Hemostáticas/instrumentación , Técnicas Hemostáticas/efectos adversosRESUMEN
BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.
Asunto(s)
Hemorragia , Torniquetes , Humanos , Hemorragia/terapia , Hemorragia/etiología , Ucrania , Heridas Relacionadas con la Guerra/terapia , Guerra , Medicina Militar , Extremidades/irrigación sanguínea , Extremidades/lesionesRESUMEN
OBJECTIVES: To derive systematic-review informed, modified Delphi consensus regarding the management of bleeding and thrombotic complications during pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE Consensus Conference. DATA SOURCES: A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION: The management of bleeding and thrombotic complications of ECMO. DATA EXTRACTION: Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twelve references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS: Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Two good practice statements, 5 weak recommendations, and 18 consensus statements are presented. CONCLUSIONS: Although bleeding and thrombotic complications during pediatric ECMO remain common, limited definitive data exist to support an evidence-based approach to treating these complications. Research is needed to improve hemostatic management of children supported with ECMO.
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Anticoagulantes , Técnica Delphi , Oxigenación por Membrana Extracorpórea , Hemorragia , Trombosis , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/métodos , Humanos , Trombosis/etiología , Trombosis/prevención & control , Hemorragia/terapia , Hemorragia/etiología , Niño , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , ConsensoRESUMEN
ABSTRACT: Background: Death due to hemorrhagic shock, particularly, noncompressible truncal hemorrhage, remains one of the leading causes of potentially preventable deaths. Automated partial and intermittent resuscitative endovascular balloon occlusion of the aorta (i.e., pREBOA and iREBOA, respectively) are lifesaving endovascular strategies aimed to achieve quick hemostatic control while mitigating distal ischemia. In iREBOA, the balloon is titrated from full occlusion to no occlusion intermittently, whereas in pREBOA, a partial occlusion is maintained. Therefore, these two interventions impose different hemodynamic conditions, which may impact coagulation and the endothelial glycocalyx layer. In this study, we aimed to characterize the clotting kinetics and coagulopathy associated with iREBOA and pREBOA, using thromboelastography (TEG). We hypothesized that iREBOA would be associated with a more hypercoagulopathic response compared with pREBOA due to more oscillatory flow. Methods: Yorkshire swine (n = 8/group) were subjected to an uncontrolled hemorrhage by liver transection, followed by 90 min of automated pREBOA, iREBOA, or no balloon support (control). Hemodynamic parameters were continuously recorded, and blood samples were serially collected during the experiment (i.e., eight key time points: baseline (BL), T0, T10, T30, T60, T90, T120, T210 min). Citrated kaolin heparinase assays were run on a TEG 5000 (Haemonetics, Niles, IL). General linear mixed models were employed to compare differences in TEG parameters between groups and over time using STATA (v17; College Station, TX), while adjusting for sex and weight. Results: As expected, iREBOA was associated with more oscillations in proximal pressure (and greater magnitudes of peak pressure) because of the intermittent periods of full aortic occlusion and complete balloon deflation, compared to pREBOA. Despite these differences in acute hemodynamics, there were no significant differences in any of the TEG parameters between the iREBOA and pREBOA groups. However, animals in both groups experienced a significant reduction in clotting times (R time: P < 0.001; K time: P < 0.001) and clot strength (MA: P = 0.01; G: P = 0.02) over the duration of the experiment. Conclusions: Despite observing acute differences in peak proximal pressures between the iREBOA and pREBOA groups, we did not observe any significant differences in TEG parameters between iREBOA and pREBOA. The changes in TEG profiles were significant over time, indicating that a severe hemorrhage followed by both pREBOA and iREBOA can result in faster clotting reaction times (i.e., R times). Nevertheless, when considering the significant reduction in transfusion requirements and more stable hemodynamic response in the pREBOA group, there may be some evidence favoring pREBOA usage over iREBOA.
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Oclusión con Balón , Modelos Animales de Enfermedad , Resucitación , Choque Hemorrágico , Tromboelastografía , Animales , Porcinos , Oclusión con Balón/métodos , Choque Hemorrágico/terapia , Resucitación/métodos , Trastornos de la Coagulación Sanguínea/terapia , Trastornos de la Coagulación Sanguínea/etiología , Coagulación Sanguínea/efectos de los fármacos , Hemorragia/terapia , Hemodinámica , Femenino , MasculinoRESUMEN
BACKGROUND: Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS: Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS: We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION: The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.
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Medicina Militar , Personal Militar , Humanos , Masculino , Medicina Militar/educación , Femenino , Adulto , Francia , Heridas Relacionadas con la Guerra/cirugía , Heridas Relacionadas con la Guerra/terapia , Sistema de Registros , Hemorragia/terapia , Torso/lesiones , Torso/cirugía , Traumatología/educación , Puntaje de Gravedad del TraumatismoRESUMEN
During extracorporeal membrane oxygenation (ECMO) support, the high shear stress in the ECMO circuit results in increased proteolysis of von Willebrand factor (VWF), loss of VWF high-molecular-weight multimers, and impaired ability to bind to platelets and collagen. These structural changes in VWF are consistent with acquired von Willebrand syndrome (AVWS) type 2A and may contribute to the bleeding diathesis frequently observed in ECMO patients. We performed a systematic review of all clinical studies evaluating the prevalence and associated outcomes of AVWS in ECMO patients. Our findings suggest that almost all ECMO patients develop partial or complete loss of VWF high-molecular-weight multimers within a few hours of device implantation. The AVWS persists as long as the patient is supported by ECMO. Weaning from ECMO rapidly and completely resolves the AVWS. Nevertheless, few studies have reported bleeding outcomes in ECMO patients with AVWS, and the extent to which AVWS contributes to the bleeding diathesis during ECMO support cannot be determined by current evidence. Data supporting the use of VWF concentrates to prevent bleeding complications in ECMO patients remain limited.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Enfermedades de von Willebrand , Factor de von Willebrand , Humanos , Oxigenación por Membrana Extracorpórea/efectos adversos , Enfermedades de von Willebrand/sangre , Enfermedades de von Willebrand/terapia , Factor de von Willebrand/metabolismo , Hemostasis , Hemorragia/terapia , Hemorragia/sangre , Hemorragia/etiología , Cuidados Críticos , Atención Perioperativa , Trombosis/sangre , Trombosis/etiología , Trombosis/prevención & control , Resultado del Tratamiento , Factores de RiesgoRESUMEN
BACKGROUND: Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage. CASE PRESENTATION: A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful. CONCLUSION: We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.