| 1. |
- Aneman, Anders, et al.
(author)
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Vasopressor Responsiveness Beyond Arterial Pressure : A Conceptual Systematic Review Using Venous Return Physiology
- 2021
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In: Shock. - : Lippincott Williams & Wilkins. - 1073-2322 .- 1540-0514. ; 56:3, s. 352-359
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Research review (peer-reviewed)abstract
- We performed a systematic review to investigate the effects of vasopressor-induced hemodynamic changes in adults with shock. We applied a physiological approach using the interacting domains of intravascular volume, heart pump performance, and vascular resistance to structure the interpretation of responses to vasopressors. We hypothesized that incorporating changes in determinants of cardiac output and vascular resistance better reflect the vasopressor responsiveness beyond mean arterial pressure alone. We identified 28 studies including 678 subjects in Pubmed, EMBASE, and CENTRAL databases. All studies demonstrated significant increases in mean arterial pressure (MAP) and systemic vascular resistance during vasopressor infusion. The calculated mean systemic filling pressure analogue increased (16 +/- 3.3 mmHg to 18 +/- 3.4 mmHg; P = 0.02) by vasopressors with variable effects on central venous pressure and the pump efficiency of the heart leading to heterogenous changes in cardiac output. Changes in the pressure gradient for venous return and cardiac output, scaled by the change in MAP, were positively correlated (r (2) = 0.88, P < 0.001). Changes in the mean systemic filling pressure analogue and heart pump efficiency were negatively correlated (r (2) = 0.57, P < 0.001) while no correlation was found between changes in MAP and heart pump efficiency. We conclude that hemodynamic changes induced by vasopressor therapy are inadequately represented by the change in MAP alone despite its common use as a clinical endpoint. The more comprehensive analysis applied in this review illustrates how vasopressor administration may be optimized.
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| 2. |
- Barrueta Tenhunen, Annelie, et al.
(author)
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High molecular weight hyaluronan : a potential adjuvant to fluid resuscitation in abdominal sepsis?
- 2023
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In: Shock. - : Wolters Kluwer. - 1073-2322 .- 1540-0514. ; 59:5, s. 763-770
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Journal article (peer-reviewed)abstract
- While fluid resuscitation is fundamental in the treatment of sepsis-induced tissue hypo-perfusion, a sustained positive fluid balance is associated with excess mortality. Hyaluronan, an endogenous glycosaminoglycan with high affinity to water, has not been tested previously as adjuvant to fluid resuscitation in sepsis.In a prospective, parallel-grouped, blinded model of porcine peritonitis-sepsis, we randomized animals to intervention with adjuvant hyaluronan (add-on to standard therapy) (n=8) or 0.9% saline (n=8). After the onset of hemodynamic instability the animals received an initial bolus of 0.1 % hyaluronan 1 mg/kg/10 min or placebo (0.9% saline) followed by a continuous infusion of 0.1% hyaluronan (1 mg/kg/h) or saline during the experiment. We hypothesized that the administration of hyaluronan would reduce the volume of fluid administered (aiming at stroke volume variation <13%) and/or attenuate the inflammatory reaction.Total volumes of intravenous fluids infused were 17.5 ± 11 ml/kg/h vs. 19.0 ± 7 ml/kg/h in intervention and control groups, respectively (p = 0.442). Plasma IL-6 increased to 2450 (1420 – 6890) pg/ml and 3690 (1410 – 11960) pg/ml (18 hours of resuscitation) in the intervention and control groups (NS). The intervention counteracted the increase in proportion of fragmented hyaluronan associated with peritonitis-sepsis alone (mean peak elution fraction (18 hours of resuscitation) control group: 17.9 ± 0.6 vs. intervention group: 16.8 ± 0.9 (p = 0.031).In conclusion, hyaluronan did not reduce the volume needed for fluid resuscitation or decrease the inflammatory reaction, even though it counterbalanced the peritonitis induced shift towards increased proportion of fragmented hyaluronan.
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| 3. |
- Bergstrom, Anna, et al.
(author)
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Acetaminophen Attenuates Pulmonary Vascular Resistance and Pulmonary Arterial Pressure and Inhibits Cardiovascular Collapse in a Porcine Model of Endotoxemia
- 2023
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In: Shock. - : Shock Society. - 1073-2322 .- 1540-0514. ; 59:3, s. 442-448
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Journal article (peer-reviewed)abstract
- Acetaminophen (paracetamol) is often used in critically ill patients with fever and pain; however, little is known about the effects of acetaminophen on cardiovascular function during systemic inflammation. Here, we investigated the effect of acetaminophen on changes in the systemic and pulmonary circulation induced by endotoxin (0.5 μg/kg/h) in anesthetized pigs. Endotoxin infusion led to a rapid increase in pulmonary artery (PA)-pressure and pulmonary vascular resistance index (PVRI). Acetaminophen delayed and attenuated this increase. Furthermore, acetaminophen reduced tachycardia and decreased stroke volume, accompanied by systemic inflammation, without affecting inflammatory parameters such as white blood cell count and TNF-α in blood. As a proof of concept, we injected a high dose of endotoxin (100 μg), which induced rapid cardiovascular collapse in pigs. Pigs treated with acetaminophen survived with no obvious hemodynamic instability during the 50 min observation period. In conclusion, acetaminophen attenuates the effects of endotoxin on pulmonary circulation in anesthetized pigs. This may play a role in severe systemic inflammation.
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| 4. |
- Brill, Jason B., et al.
(author)
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The Role of TEG and ROTEM in Damage Control Resuscitation
- 2021
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In: Shock. - : LIPPINCOTT WILLIAMS & WILKINS. - 1073-2322 .- 1540-0514. ; 56:1S, s. 52-61
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Journal article (peer-reviewed)abstract
- Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patients arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.
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| 5. |
- Duchesne, Juan, et al.
(author)
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Delta Systolic Blood Pressure (SBP) Can be a Stronger Predictor of Mortality Than Pre-Aortic Occlusion SBP in Non-Compressible Torso Hemorrhage : an Abotrauma and AORTA Analysis
- 2021
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In: Shock. - : Biomedical Press. - 1073-2322 .- 1540-0514. ; 56:1S, s. 30-36
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Journal article (peer-reviewed)abstract
- BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is becoming a standardized adjunct for the management in patients with severe non-compressible torso hemorrhage (NCTH). Although guidelines have been developed to help with the best indications for REBOA utilization, no studies have addressed the significance of change in systolic blood pressure (ΔSBP) after REBOA insufflation. We hypothesized that ΔSBP would predict mortality in patients with NCTH and have utility as a surrogate marker for hemorrhage status.STUDY DESIGN: This was an international, multicenter retrospective review of all patients managed with REBOA from the ABOTrauma Registry and the AORTA database. ΔSBP was defined as the difference between pre- and post-REBOA insertion SBP. Based on post-insertion SBP, patient hemorrhage status was categorized as responder or non-responder. A non-responder was defined as a hypotensive patient with systolic blood pressure (SBP) < 90 mmHg after REBOA placement with full aortic occlusion. Significance was set at P < 0.05.RESULTS: A total of 524 patients with NCTH were included. Most (74%) were male, 77% blunt injured with a median (IQR) age of 40 (27 - 58) years and ISS 34 (25 - 45). Overall mortality was 51.0%. 20% of patients were classified as non-responders. Demographic and injury descriptors did not differ between groups. Mortality was significantly higher in non-responders vs responders (64% vs 46%, respectively; P = 0.001). Non-responders had lower median pre-insertion SBP (50mmHg vs 67mmHg; P < 0.001) and lower ΔSBP (20mmHg vs 48mmHg; P < 0.001).CONCLUSION: REBOA non-responders present and remain persistently hypotensive and are more likely to die than responders, indicating a potential direct correlation between ΔSBP as a surrogate marker of hemorrhage volume status and mortality. Future prospective studies will need to further elucidate the impact of Damage Control Resuscitation efforts on ΔSBP and mortality.
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| 6. |
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| 7. |
- Duchesne, Juan, et al.
(author)
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Prehospital Mortality Due to Hemorrhagic Shock Remains High and Unchanged : A Summary of Current Civilian EMS Practices and New Military Changes
- 2021
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In: Shock. - : Lippincott Williams & Wilkins. - 1073-2322 .- 1540-0514. ; 56:1S, s. 3-8
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Journal article (peer-reviewed)abstract
- Mortality secondary to trauma related hemorrhagic shock has not improved for several decades. Underlying the stall in progress is the conundrum of effective pre-hospital interventions for hemorrhage control. As we know, neither pressing hard on the gas nor "Stay and play" have changed mortality over the last 20 years. For this reason, when dealing with effective changes that will improve severe hemorrhage mortality outcomes, there is a need for the creation of a hybrid pre-hospital model.Improvements in mortality outcomes for patients with severe hemorrhage based on evidence for common civilian prehospital procedures such as in-field intubation and immediate fluid resuscitation with crystalloid solution is weak at best. The use of tourniquets, once considered too risky to use, however, has risen dramatically in large part due success seen during their use in the military. Their use in the civilian setting shows promising results. Recently updated military Advanced Resuscitative Care (ARC) guidelines propose the use of prehospital whole blood transfusion as well as in-field use of Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Several case studies from Europe suggest these strategies are feasible for use in the civilian population, but could they be implemented in the U.S.?
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| 8. |
- Hahn, Robert G., et al.
(author)
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Kinetics of Ringers Solution in Extracellular Dehydration and Hemorrhage
- 2020
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In: Shock. - : LIPPINCOTT WILLIAMS & WILKINS. - 1073-2322 .- 1540-0514. ; 53:5, s. 566-573
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Journal article (peer-reviewed)abstract
- Background: Ringers solution might be used to treat volume depletion (extracellular dehydration) and hemorrhage, but there is no integrated view of how these fluid balance disorders influence the kinetics of the infused volume. Methods: Acute dehydration (mean 1.7 L) was induced by repeated doses of furosemide (5 mg) in 10 healthy male volunteers, and 0.5 L and 0.9 L of blood was withdrawn in random order on different occasions in another 10 male volunteers, just before administration of Ringers acetate solution. Infusions performed in the normovolemic state served as controls. Measurements of blood hemoglobin and urinary excretion were used to create volume kinetic profiles that were analyzed using mixed-effects modeling software. Results: Infusions over 15 to 30 min showed a marked distribution phase during which the plasma volume transiently increased by 50% to 75% of the administered volume. Dehydration and hemorrhage accelerated redistribution but retarded the elimination; the half-life of the infused fluid increased from 36 to 51 min (mean) from 1 L of dehydration and to 95 min from 1 L of hemorrhage. Extravascular accumulation decreased with the dehydration volume and increased with the hemorrhage volume. Simulations show that 60% as much Ringer is needed to replace volume depletion amounting to 1 L as compared with hemorrhage over a 2-h period. A continued but slower drip after the initial fluid resuscitation prevents rebound hypovolemia. Conclusions: Furosemide-induced dehydration and blood withdrawal in normotensive volunteers had modest effects on the Ringers acetate kinetics. Urinary excretion was inhibited more by hemorrhage than by dehydration.
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| 9. |
- Hörer, Tal M., 1971-, et al.
(author)
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Endovascular Resuscitation and Trauma Management (EVTM) : Practical Aspects and Implementation
- 2021
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In: Shock. - : Lippincott Williams & Wilkins. - 1073-2322 .- 1540-0514. ; 56:1S, s. 37-41
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Journal article (peer-reviewed)abstract
- In recent years there has been a tremendous increase in hemorrhage control by endovascular methods. Traumatic and non-traumatic hemorrhage is being more frequently managed with endografts, embolization agents and minimal invasive methods. These methods initially were used in hemodynamically stable patients only, whereas now are being implemented in acute settings and hemodynamically unstable patients. The strategy of using endovascular and combined open-endo methods approach for hemodynamic instability in trauma and non-trauma patients has been named EVTM- EndoVascular resuscitation and Trauma Management. The EVTM concept will be presented in this article, describing how it is developed and used, as well as its limitations and future aspects.
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| 10. |
- Kauvar, David, et al.
(author)
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Challenges and Opportunities for Endovascular Treatment of Hemorrhage in Combat Casualty Care
- 2021
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In: Shock. - : Lippincott Williams & Wilkins. - 1073-2322 .- 1540-0514. ; 56:1S, s. 46-51
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Journal article (peer-reviewed)abstract
- ABSTRACT: The care of the hemorrhaging patient continues to evolve. The use of endovascular techniques to treat hemorrhage has increased significantly in civilian trauma care over the past 15 years and is identified as a major national trauma care research priority. Endovascular techniques are being increasingly employed to treat major thoracoabdominal arterial injuries and resuscitative endovascular balloon occlusion of the aorta is being adopted at trauma centers as a supportive adjunct to resuscitation in the exsanguinating patient. Emerging endovascular technology offers the opportunity to provide temporary or permanent control of non-compressible torso hemorrhage, which remains a vexing problem in combat casualty care. Endovascular advances have not been translated to the care of combat casualties to any significant degree, however. This review provides a summary and analysis of the gap between civilian endovascular hemorrhage control and combat casualty care practice to better align future research and development efforts.
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