Role of Serial Phlebotomy in the Management of Blunt Solid Organ Injury in Adults.

BACKGROUND: The management of blunt spleen and liver trauma has become increasingly nonoperative. There is no consensus on timing or duration of serial hemoglobin and hematocrit monitoring in this patient population. OBJECTIVE: This study examined the clinical utility of serial hemoglobin and hematocrit monitoring. We hypothesized that most interventions occur early in the hospital course, based on hemodynamic instability or physical examination findings rather than serial monitoring. METHODS: We conducted a retrospective cohort study of adult trauma patients with blunt spleen or liver injury from November 2014 through June 2019 at our Level II trauma center. Interventions were classified as no intervention, surgical intervention, angioembolization, or packed red blood cell transfusion. Demographics, length of stay, total blood draws, laboratory values, and clinical triggers preceding intervention were reviewed. RESULTS: A total of 143 patients were studied, of whom 73 (51%) received no intervention, 47 (33%) received an intervention within 4 hr of presentation, and 23 (16%) had interventions beyond 4 hr. Of these 23 patients, 13 received an intervention based on phlebotomy results alone. Most of these patients (n = 12, 92%) received blood transfusion without further intervention. Only one patient underwent operative intervention based on serial hemoglobin results on hospital day 2. CONCLUSION: The majority of patients with these injury patterns either require no intervention or declare themselves promptly after arrival. Serial phlebotomy after initial triage and intervention may add little value in the management of blunt solid organ injury.

Recombinant activated protein C induces dose-dependent changes in inflammatory mediators, tissue damage, and apoptosis in in vivo rat model of sepsis.

BACKGROUND: Sepsis is the tenth leading cause of death in the U.S. and creates a $16.7 billion burden on the healthcare system every year. Sepsis is characterized by a severe uncontrolled inflammatory response to the infection. Various cells and mediators are activated, and the result is a complex interaction between the inflammation and coagulation cascades leading to capillary leakage and end-organ ischemia. Current therapeutic strategies, such as recombinant human activated protein C, focus on this interplay. However, this drug's precise mechanism of action is not well understood. The aim of this study was to assess cytokine production, tissue damage, and apoptosis in a rat model of sepsis in response to various doses of this drug. METHODS: Sprague-Dawley rats were divided into eight groups, including negative control, sham, sepsis only, and five treatment groups. The sepsis and treatment groups were given Escherichia coli. Each of the treatment groups received a different dose of recombinant activated protein C to complete 30-min or 270-min infusion times from the onset of sepsis. Serum and tissue samples were collected. Interleukin (IL)-6 concentrations were measured, and serum malondialdehyde (MDA) concentrations were determined to assess generalized tissue damage. Apoptosis in the lung was evaluated using a semi-quantitative ligation-mediated polymerase chain reaction assay. RESULTS: The physiologic effects of recombinant activated protein C are dose dependent and determined by the duration of infusion. Higher doses of the drug were associated with less inflammation, apoptosis, and generalized tissue damage. Sepsis increased the mean concentration of MDA (2.1 vs. 10.9 pmol/mg of protein) and IL-6 (0 vs. 10,763 pg/mL) compared with sham-treated animals, as well as the magnitude of apoptosis in lung (2,037 vs. 8,709 pixels) (all p < 0.05). Infusion of recombinant activated protein C attenuated these responses in a dose-response manner. Interleukin-6 and MDA concentrations were increased by lower-dose therapy, but attenuated significantly by the higher-dose infusion at 5 mg/kg/h. Apoptosis was attenuated by both the lower and the higher dose, but more so with the higher dose. CONCLUSIONS: These data can assist in establishing an optimal dose and infusion time of this drug for extrapolation to therapy of human beings. The goal now is to elucidate these findings further so that the maximum benefit of the drug may be achieved with the least possible harmful effects.

The effect of shock resuscitation fluids on apoptosis.

BACKGROUND: Recent data suggest that the type of resuscitation fluid used to treat hemorrhagic shock contributes to cellular dysfunction METHODS: Rats were hemorrhaged, exposed to a hypovolemic shock period for 75 minutes, and then resuscitated for 1 hour. Treatment animals were assigned randomly to lactate Ringer's solution, normal saline solution, bicarbonate Ringer's solution, hypertonic saline solution, rat plasma solution, ketone Ringer's solution, or nonresuscitation. After resuscitation, lung and liver samples were collected and evaluated for apoptosis by using ligation-mediated polymerase chain reaction. RESULTS: Nonresuscitated shock rats had significantly higher levels of apoptosis in lung and liver. Rats treated with normal saline solution, bicarbonate Ringer's solution, ketone Ringer's solution, and hypertonic saline solution had significantly lower levels of apoptosis in lung compared with nonresuscitated animals. Rats treated with bicarbonate Ringer's solution and ketone Ringer's solution had significantly lower levels of apoptosis in liver tissue when compared with nonresuscitated animals. CONCLUSIONS: Cellular damage results from hemorrhagic shock. The use of resuscitation fluids decreases apoptosis during shock.