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Minerva Anestesiologica Oct 2011Over the last two decades, experimental and clinical data have begun to shape a more discriminating approach to intravascular (IV) fluid infusions in the resuscitation... (Review)
Review
Over the last two decades, experimental and clinical data have begun to shape a more discriminating approach to intravascular (IV) fluid infusions in the resuscitation of trauma patients with presumed internal hemorrhage. This approach takes into account the presence of potentially uncontrollable hemorrhage (e.g., deep intra-abdominal or intra-thoracic injury) versus a controllable source (e.g. distal extremity wound). This limitation on fluid resuscitation is particularly applicable in the case of patients with penetrating truncal injury being transported rapidly to a nearby definitive care center. Meanwhile, longstanding debates over the type of fluid that should be infused remain largely unresolved and further complicated by recent clinical trials that did not demonstrate support for either hemoglobin-based oxygen carriers or hypertonic saline. However, there is also growing evidence that does support the increased use of fresh frozen plasma as well as tourniquets, and intra-osseous devices. While a more discriminating approach to fluid infusions have evolved, it has also become clear that positive pressure ventilatory support should be limited in the face of potential severe hemorrhage due to the accompanying reductions in venous return. Controversies over prehospital endotracheal tube placement are confounded by this factor as well as the effects of paramedic deployment strategies and related skills usage. Beyond these traditional areas of focus, a number of very compelling clinical observations and an extensive body of experimental data has generated a very persuasive argument that intravenous estrogen and progesterone may be of value in trauma management, particularly severe traumatic brain injury and burns.
Topics: Blood Volume; Catheters, Indwelling; Fluid Therapy; Gonadal Steroid Hormones; Hemostasis; Humans; Plasma Substitutes; Positive-Pressure Respiration; Resuscitation; Wounds and Injuries; Wounds, Nonpenetrating; Wounds, Penetrating
PubMed: 21952600
DOI: No ID Found -
Journal of Cerebral Blood Flow and... Jul 2017The critical role of the vasculature and its repair in neurological disease states is beginning to emerge particularly for stroke, dementia, epilepsy, Parkinson's... (Review)
Review
The critical role of the vasculature and its repair in neurological disease states is beginning to emerge particularly for stroke, dementia, epilepsy, Parkinson's disease, tumors and others. However, little attention has been focused on how the cerebral vasculature responds following traumatic brain injury (TBI). TBI often results in significant injury to the vasculature in the brain with subsequent cerebral hypoperfusion, ischemia, hypoxia, hemorrhage, blood-brain barrier disruption and edema. The sequalae that follow TBI result in neurological dysfunction across a host of physiological and psychological domains. Given the importance of restoring vascular function after injury, emerging research has focused on understanding the vascular response after TBI and the key cellular and molecular components of vascular repair. A more complete understanding of vascular repair mechanisms are needed and could lead to development of new vasculogenic therapies, not only for TBI but potentially vascular-related brain injuries. In this review, we delineate the vascular effects of TBI, its temporal response to injury and putative biomarkers for arterial and venous repair in TBI. We highlight several molecular pathways that may play a significant role in vascular repair after brain injury.
Topics: Animals; Biomarkers; Blood-Brain Barrier; Brain Injuries, Traumatic; Cerebral Arteries; Cerebral Veins; Cerebrovascular Circulation; Fibroblast Growth Factor 2; Humans; Neovascularization, Physiologic; Vascular Endothelial Growth Factor A
PubMed: 28378621
DOI: 10.1177/0271678X17701460 -
Journal of Vascular Surgery. Venous and... Nov 2021Venous injury to the inferior vena cava or iliac veins is rare but can result in high mortality rates. Traditional treatment by repair or ligation can be technically...
OBJECTIVE
Venous injury to the inferior vena cava or iliac veins is rare but can result in high mortality rates. Traditional treatment by repair or ligation can be technically demanding. A relatively new treatment modality is the use of a covered stent to cover the venous defect. The aim of the present systematic review was to assess the techniques, results, and challenges of covered stent graft repair of traumatic injury to the inferior vena cava and iliac veins.
METHODS
The PubMed (Medline) and Embase databases were systematically searched up to September 2020 by two of us (R.R.S. and D.D.) independently for studies reporting on covered stenting of the inferior vena cava or iliac veins after traumatic or iatrogenic injury. A methodologic quality assessment was performed using the modified Newcastle-Ottawa scale. Data were extracted for the following parameters: first author, year of publication, study design, number of patients, type and diameter of the stent graft, hemostatic success, complications, mortality, postoperative medication, follow-up type and duration, and venous segment patency. The main outcome was clinical success of the intervention, defined as direct hemostasis, with control of hemorrhage, hemodynamic recovery, and absence of contrast extravasation.
RESULTS
From the initial search, which yielded 1884 records, a total of 28 studies were identified for analysis. All reports consisted of case reports, except for one retrospective cohort study and one case series. A total of 35 patients had been treated with various covered stent grafts, predominantly thoracic or abdominal aortic endografts. In all patients, the treatment was technically successful. The 30-day mortality rate for the entire series was 2.9%. Three perioperative complications were described: one immediate stent occlusion, one partial thrombosis, and one pulmonary embolism. Additional in-stent thrombus formation was seen during follow-up in three patients, leading to one stent graft occlusion (asymptomatic). The postoperative anticoagulation strategy was highly heterogeneous. The median follow-up was 3 months (range, 0.1-84 months). However, follow-up with imaging studies was not performed in all cases.
CONCLUSIONS
In selected cases of injury to the inferior vena cava and iliac veins, covered stent grafts can be successful for urgent hemostasis with good short-term results. Data on long-term follow-up are very limited.
Topics: Humans; Iliac Vein; Prosthesis Design; Stents; Vascular Surgical Procedures; Vena Cava, Inferior
PubMed: 33771733
DOI: 10.1016/j.jvsv.2021.03.008 -
HPB : the Official Journal of the... Jun 2010This study seeks to identify factors for hepatectomy in the management of post-cholecystectomy bile duct injury (BDI) and outcome via a systematic review of the... (Review)
Review
OBJECTIVES
This study seeks to identify factors for hepatectomy in the management of post-cholecystectomy bile duct injury (BDI) and outcome via a systematic review of the literature.
METHODS
Relevant literature was found by searching the PubMed database and the bibliographies of extracted articles. To avoid bias selection, factors for hepatectomy were analysed in series reporting both patients undergoing hepatectomy and patients undergoing biliary repair without hepatectomy (bimodal treatment). Relevant variables were the presence or absence of additional hepatic artery and/or portal vein injury, the level of BDI, and a previous biliary repair.
RESULTS
Among 460 potentially relevant publications, only 31 met the eligibility criteria. A total of 99 hepatectomies were reported among 1756 (5.6%) patients referred for post-cholecystectomy BDI. In eight series reporting bimodal treatment, including 232 patients, logistic regression multivariate analysis showed that hepatic arterial and Strasberg E4 and E5 injuries were independent factors associated with hepatectomy. Patients with combined arterial and Strasberg E4 or E5 injury were 43.3 times more likely to undergo hepatectomy (95% confidence interval 8.0-234.2) than patients without complex injury. Despite high postoperative morbidity, mortality rates were comparable with those of hepaticojejunostomy, except in urgent hepatectomies (within 2 weeks; four of nine patients died). Longterm outcome was satisfactory in 12 of 18 patients in the largest series.
CONCLUSIONS
Hepatectomies were performed mainly in patients showing complex concurrent Strasberg E4 or E5 and hepatic arterial injury and provided satisfactory longterm outcomes despite high postoperative morbidity.
Topics: Bile Ducts; Chi-Square Distribution; Cholecystectomy, Laparoscopic; Hepatectomy; Hepatic Artery; Humans; Iatrogenic Disease; Logistic Models; Patient Selection; Portal Vein; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Wounds and Injuries
PubMed: 20590909
DOI: 10.1111/j.1477-2574.2010.00172.x -
Seminars in Radiation Oncology Oct 2011The refinement of radiation therapy and radioembolization techniques has led to a resurgent interest in radiation-induced liver disease (RILD). The awareness of... (Review)
Review
The refinement of radiation therapy and radioembolization techniques has led to a resurgent interest in radiation-induced liver disease (RILD). The awareness of technical and clinical parameters that influence the chance of RILD is important to guide patient selection and toxicity minimization strategies. "Classic" RILD is characterized by anicteric ascites and hepatomegaly and is unlikely to occur after a mean liver dose of approximately 30 Gy in conventional fractionation. By maintaining a low mean liver dose and sparing a "critical volume" of liver from radiation, stereotactic delivery techniques allow for the safe administration of higher tumor doses. Caution must be exercised for patients with hepatocellular carcinoma or pre-existing liver disease (eg, Child-Pugh score of B or C) because they are more susceptible to RILD that can manifest in a nonclassic pattern. Although no pharmacologic interventions have yet been proven to mitigate RILD, preclinical research shows the potential for therapies targeting transforming growth factor-β and for the transplantation of stem cells, hepatocytes, and liver progenitor cells as strategies that may restore liver function. Also, in the clinical setting of veno-occlusive liver disease after high-dose chemotherapy, agents with fibrinolytic and antithrombotic properties can reverse liver failure, suggesting a possible role in the setting of RILD.
Topics: Dose-Response Relationship, Radiation; Hepatic Veins; Humans; Liver; Radiation Injuries; Radiotherapy
PubMed: 21939854
DOI: 10.1016/j.semradonc.2011.05.003 -
Journal of Ayub Medical College,... 2022Penetrating heart injuries are associated with higher mortality rates. Coronary lesions caused by penetrating trauma are considered even rarer and universally fatal. We...
Penetrating heart injuries are associated with higher mortality rates. Coronary lesions caused by penetrating trauma are considered even rarer and universally fatal. We present a case of a fortunate survivor who had complete transection of left anterior descending (LAD) artery with right ventricular (RV) tear after being stabbed by knife, arriving in emergency unit with massively bleeding chest wound. Complex cardiac trauma involving coronaries and cardiac chambers is a challenge to surgeons if patients miraculously reach the hospital alive. This patient had complete transection of LAD artery with penetration into RV cavity, he was successfully managed by timely and prompt surgical intervention by on call team. This case highlights the importance of team dynamics working in harmony during emergency situations, we stress upon conducting routine drills to train surgical residents, perfusionists and operation theatre staff.
Topics: Male; Humans; Wounds, Stab; Wounds, Penetrating; Thoracic Injuries; Heart Injuries; Coronary Vessels
PubMed: 36550672
DOI: 10.55519/JAMC-04-S4-10328 -
Journal of Pediatric Surgery Apr 2017The implications of childhood obesity on pediatric trauma outcomes are not clearly established. Anthropomorphic data were recently added to the National Trauma Data Bank...
BACKGROUND/PURPOSE
The implications of childhood obesity on pediatric trauma outcomes are not clearly established. Anthropomorphic data were recently added to the National Trauma Data Bank (NTDB) Research Datasets, enabling a large, multicenter evaluation of the effect of obesity on pediatric trauma patients.
METHODS
Children ages 2 to 19years who required hospitalization for traumatic injury were identified in the 2013-2014 NTDB Research Datasets. Age and gender-specific body mass indices (BMI) were calculated. Outcomes included injury patterns, operative procedures, complications, and hospital utilization parameters.
RESULTS
Data from 149,817 pediatric patients were analyzed; higher BMI percentiles were associated with significantly more extremity injuries, and fewer injuries to the head, abdomen, thorax and spine (p values <0.001). On multivariable analysis, higher BMI percentiles were associated with significantly increased likelihood of death, deep venous thrombosis, pulmonary embolus and pneumonia; although there was no difference in risk of overall complications. Obese children also had significantly longer lengths of stay and more frequent ventilator requirement.
CONCLUSIONS
Among children admitted after trauma, increased BMI percentile is associated with increased risk of death and potentially preventable complications. These findings suggest that obese children may require different management than nonobese counterparts to prevent complications.
LEVEL OF EVIDENCE
Level III; prognosis study.
Topics: Adolescent; Body Mass Index; Child; Child, Preschool; Databases, Factual; Female; Hospitalization; Humans; Male; Pediatric Obesity; Pneumonia; Prognosis; Pulmonary Embolism; Respiration, Artificial; Retrospective Studies; Risk Factors; Surgical Procedures, Operative; Trauma Severity Indices; United States; Venous Thrombosis; Wounds and Injuries; Young Adult
PubMed: 27914588
DOI: 10.1016/j.jpedsurg.2016.11.037 -
Angiogenesis May 2021Endothelial cells display an extraordinary plasticity both during development and throughout adult life. During early development, endothelial cells assume arterial,... (Review)
Review
Endothelial cells display an extraordinary plasticity both during development and throughout adult life. During early development, endothelial cells assume arterial, venous, or lymphatic identity, while selected endothelial cells undergo additional fate changes to become hematopoietic progenitor, cardiac valve, and other cell types. Adult endothelial cells are some of the longest-lived cells in the body and their participation as stable components of the vascular wall is critical for the proper function of both the circulatory and lymphatic systems, yet these cells also display a remarkable capacity to undergo changes in their differentiated identity during injury, disease, and even normal physiological changes in the vasculature. Here, we discuss how endothelial cells become specified during development as arterial, venous, or lymphatic endothelial cells or convert into hematopoietic stem and progenitor cells or cardiac valve cells. We compare findings from in vitro and in vivo studies with a focus on the zebrafish as a valuable model for exploring the signaling pathways and environmental cues that drive these transitions. We also discuss how endothelial plasticity can aid in revascularization and repair of tissue after damage- but may have detrimental consequences under disease conditions. By better understanding endothelial plasticity and the mechanisms underlying endothelial fate transitions, we can begin to explore new therapeutic avenues.
Topics: Animals; Arteries; Cell Differentiation; Endothelial Cells; Hematopoietic Stem Cells; Humans; Lymphatic Vessels; Neovascularization, Physiologic; Veins; Wounds and Injuries; Zebrafish
PubMed: 33449300
DOI: 10.1007/s10456-020-09761-7 -
Biochemical and Biophysical Research... May 2020Smoke inhalation injury (SII) affects more than 50,000 people annually causing carbon monoxide (CO) poisoning. Although the increased blood level of carboxyhemoglobin...
Blood carboxyhemoglobin elimination curve, half-lifetime, and arterial-venous differences in acute phase of carbon monoxide poisoning in ovine smoke inhalation injury model.
Smoke inhalation injury (SII) affects more than 50,000 people annually causing carbon monoxide (CO) poisoning. Although the increased blood level of carboxyhemoglobin (CO-Hb) is frequently used to confirm the diagnosis of SII, knowledge of its elimination in the acute phase is still limited. The aim of this study is to determine CO-Hb elimination rates and their differences in arterial (aCO-Hb) and mixed-venous (vCO-Hb) blood following severe SII in a clinically relevant ovine model. Forty-three chronically instrumented female sheep were subjected to SII (12 breaths, 4 sets) through tracheostomy tube under anesthesia and analgesia. After the SII, sheep were awakened and placed on a mechanical ventilator (FiO = 1.0, tidal volume 12 mL/kg, and PEEP = 5cmHO) and monitored. Arterial and mixed-venous blood samples were withdrawn simultaneously for blood gas analysis at various time points to determine CO-HB half-lifetime and an elimination curve. The mean of highest aCO-Hb level during SII was 70.8 ± 13.9%. The aCO-Hb elimination curve showed an approximated exponential decay during the first 60 min. Per mixed linear regression model analysis, aCO-Hb significantly (p < 0.001) declined (4.3%/minute) with a decay constant lambda of 0.044. With this lambda, mean lifetime and half-lifetime of aCO-Hb were 22.7 and 15.7 min, respectively. The aCO-Hb was significantly lower compared to vCO-Hb at all-time points (0-180 min). To our knowledge, this is the first report describing CO-Hb elimination curve in the acute phase after severe SII in the clinically relevant ovine model. Our data shows that CO-Hb is decreasing in linear manner with supportive mechanical ventilation (0-60 min). The results may help to understand CO-Hb elimination curve in the acute phase and improvement of pre-hospital and initial clinical care in patients with CO poisoning.
Topics: Acute Disease; Animals; Arteries; Carbon Monoxide Poisoning; Carboxyhemoglobin; Disease Models, Animal; Female; Half-Life; Hemodynamics; Sheep; Smoke Inhalation Injury; Veins
PubMed: 32199614
DOI: 10.1016/j.bbrc.2020.03.048 -
The Journal of Trauma and Acute Care... Jan 2021Following trauma, persistent inflammation, immunosuppression, and catabolism may characterize delayed recovery or failure to recover. Understanding the metabolic...
BACKGROUND
Following trauma, persistent inflammation, immunosuppression, and catabolism may characterize delayed recovery or failure to recover. Understanding the metabolic response associated with these adverse outcomes may facilitate earlier identification and intervention. We characterized the metabolic profiles of trauma victims who died or developed chronic critical illness (CCI) and hypothesized that differences would be evident within 1-week postinjury.
METHODS
Venous blood samples from trauma victims with shock who survived at least 7 days were analyzed using mass spectrometry. Subjects who died or developed CCI (intensive care unit length of stay of ≥14 days with persistent organ dysfunction) were compared with subjects who recovered rapidly (intensive care unit length of stay, ≤7 days) and uninjured controls. We used partial least squares discriminant analysis, t tests, linear mixed effects regression, and pathway enrichment analyses to make broad comparisons and identify differences in metabolite concentrations and pathways.
RESULTS
We identified 27 patients who died or developed CCI and 33 who recovered rapidly. Subjects were predominantly male (65%) with a median age of 53 years and Injury Severity Score of 36. Healthy controls (n = 48) had similar age and sex distributions. Overall, from the 163 metabolites detected in the samples, 56 metabolites and 21 pathways differed between injury outcome groups, and partial least squares discriminant analysis models distinguished injury outcome groups as early as 1-day postinjury. Differences were observed in tryptophan, phenylalanine, and tyrosine metabolism; metabolites associated with oxidative stress via methionine metabolism; inflammatory mediators including kynurenine, arachidonate, and glucuronic acid; and products of the gut microbiome including indole-3-propionate.
CONCLUSIONS
The metabolic profiles in subjects who ultimately die or develop CCI differ from those who have recovered. In particular, we have identified differences in markers of inflammation, oxidative stress, amino acid metabolism, and alterations in the gut microbiome. Targeted metabolomics has the potential to identify important metabolic changes postinjury to improve early diagnosis and targeted intervention.
LEVEL OF EVIDENCE
Prognostic/epidemiologic, level III.
Topics: Adult; Aged; Chronic Disease; Critical Illness; Female; Humans; Length of Stay; Male; Metabolomics; Middle Aged; Treatment Outcome; Wounds and Injuries
PubMed: 33017357
DOI: 10.1097/TA.0000000000002952