Ischemia-modified albumin and the IMA/albumin ratio in the diagnosis and staging of hemorrhagic shock: A randomized controlled experimental study.

BACKGROUND: To determine the value of ischemia-modified albumin (IMA) and IMA/albumin ratio (IMAR) in the diagnosis and staging of hemorrhagic shock (HS). METHODS: A pressure-targeted HS model was established in this study. The control and shock groups were monitored for 30 min and 60 min to simulate varying durations of exposure to HS. All subjects underwent invasive arterial monitoring during the experiment and were further divided into mild and severe shock groups based on decreases in mean arterial pressure (MAP). Biochemical and histologic comparisons were performed between the groups. RESULTS: Our results revealed higher IMA, IMAR, lactate, total oxidant status (TOS) and oxidative stress index (OSI) levels in both the 30- and 60-min shock groups compared to the control group. Concerning MAP-based shock staging, IMA, IMAR, lactate, TOS and OSI levels in the 30-min and 60-min mild and severe shock groups were higher than those of the controls. However, there was no significant difference between the mild and severe shock groups. A significant correlation was determined between all the biomarkers evaluated and HS-induced damage in various organs. This correlation was highest in lactate and IMAR levels. CONCLUSION: IMA and IMAR levels may be used in the early diagnosis of HS and also have the potential for use in determining the severity of HS. IMA and IMAR measurement may also be considered as an alternative or in addition to lactate measurement in the diagnosis of HS.

The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients.

PURPOSE: Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score). METHODS: We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT. RESULTS: We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = <0.0001). Mortality was higher in the MT group (45.5% vs 15.3%, p = 0.0004). CONCLUSIONS: The ABCD score improves the sensitivity of activating MT in pediatric trauma patients. STUDY TYPE: Treatment Study. LEVEL OF EVIDENCE: Level III.

Feasibility of optical coherence tomography angiography to assess changes in retinal microcirculation in ovine haemorrhagic shock.

BACKGROUND: This study aimed to investigate the feasibility of optical coherence tomography angiography (OCT-A) for quantitative analysis of flow density to assess changes in retinal perfusion in an experimental model of haemorrhagic shock. METHODS: Haemorrhagic shock was induced in five healthy, anaesthetized sheep by stepwise blood withdrawal of 3 × 10 ml∙kg- 1 body weight. OCT-A imaging of retinal perfusion was performed using an OCT device. Incident dark-field illumination microscopy videos were obtained for the evaluation of conjunctival microcirculation. Haemodynamic variables and flow density data in the OCT angiogram were analysed before and during progressive haemorrhage resulting in haemorrhagic shock as well as after fluid resuscitation with 10 ml∙kg- 1 body weight of balanced hydroxyethyl starch solution (6% HES 130/0.4). Videos of the conjunctival microcirculation were recorded at baseline, in haemorrhagic shock, and after resuscitation. Data are presented as median with interquartile range. Comparisons between time points were made using Friedman's test and the degree of correlation between two variables was expressed as Spearman's rank correlation coefficient. RESULTS: Mean arterial pressure and cardiac index (CI) decreased and lactate concentration increased after induction of shock, and haemodynamics recovered after resuscitation. The flow density in the superficial retinal OCT angiogram decreased significantly after shock induction (baseline 44.7% (40.3; 50.5) vs haemorrhagic shock 34.5% (32.8; 40.4); P = 0.027) and recovered after fluid resuscitation (46.9% (41.7; 50.7) vs haemorrhagic shock; P = 0.027). The proportion of perfused vessels of the conjunctival microcirculation showed similar changes. The flow density measured using OCT-A correlated with the conjunctival microcirculation (perfused vessel density: Spearman's rank correlation coefficient ρ = 0.750, P = 0.001) and haemodynamic parameters (CI: ρ = 0.693, P < 0.001). CONCLUSIONS: Retinal flow density, measured using OCT-A, significantly decreased in shock and recovered after fluid therapy in an experimental model of haemorrhagic shock. OCT-A is feasible to assess changes in retinal perfusion in haemorrhagic shock and fluid resuscitation.

Clinical features and management of haemorrhagic shock.

This article discusses the clinical features of haemorrhagic shock and the strategies used to manage the condition, focusing on the presenting symptoms, classifications, compensatory mechanisms, physiological changes and nursing interventions. Haemorrhagic shock is a condition of reduced tissue perfusion as a result of the inadequate delivery of oxygen and nutrients necessary for cellular function. The condition is secondary to large-volume blood loss, often associated with trauma or complications following surgical or medical procedures. Identifying and stopping the source of the uncontrolled bleeding is essential. Because of the life-threatening nature of the condition, it is important that haemorrhagic shock is identified promptly and appropriate management is commenced without delay.

[Hemorrhagic shock]. / Choc hémorragique.

Shock is a life threatening condition. The management of an hemorrhagic shock, whether traumatic or not, requires early identification of the bleeding source and adequate hemodynamic support. The diagnosis accuracy is based on clinical, hemodynamic, radiologic and biochemical findings which also allow appraisal of the treatment efficiency. Treatment should be goal-oriented with rapid hemorrhage control by surgery, interventional radiology or drug support. Circulatory resuscitation is aimed to restore adequate tissue perfusion and oxygenation and should be closely monitored.

Angiotensin (1-7) contributes to nitric oxide tonic inhibition of vasopressin release during hemorrhagic shock in acute ethanol intoxicated rodents.

AIMS: Acute ethanol intoxication (AEI) attenuates the arginine vasopressin (AVP) response to hemorrhage leading to impaired hemodynamic counter-regulation and accentuated hemodynamic stability. Previously we identified that the ethanol-induced impairment of circulating AVP concentrations in response to hemorrhage was the result of augmented central nitric oxide (NO) inhibition. The aim of the current study was to examine the mechanisms underlying ethanol-induced up-regulation of paraventricular nucleus (PVN) NO concentration. Angiotensin (ANG) (1-7) is an important mediator of NO production through activation of the Mas receptor. We hypothesized that Mas receptor inhibition would decrease central NO concentration and thus restore the rise in circulating AVP levels during hemorrhagic shock in AEI rats. MAIN METHODS: Conscious male Sprague-Dawley rats (300-325 g) received a 15 h intra-gastric infusion of ethanol (2.5 g/kg+300 mg/kg/h) or dextrose prior to a fixed-pressure (~40 mm Hg) 60 min hemorrhage. The Mas receptor antagonist A-779 was injected through an intracerebroventricular (ICV) cannula 15 min prior to hemorrhage. KEY FINDINGS: PVN NOS activity and NO were significantly higher in AEI compared to DEX-treated controls at the completion of hemorrhage. ICV A-779 administration decreased NOS activity and NO concentration, partially restoring the rise in circulating AVP level at completion of hemorrhage in AEI rats. SIGNIFICANCE: These results suggest that Mas receptor activation contributes to the NO-mediated inhibitory tone of AVP release in the ethanol-intoxicated hemorrhaged host.

[The usefulness of severity scoring systems in elderly intensive care unit (ICU) patients with non-traumatic haemorrhagic shock]. / Przydatnosc powszechnie stosowanych skal w oddziale intensywnej terapii do oceny stanu chorych w podeszlym wieku leczonych z powodu wstrzasu krwotocznego nie-pourazowego.

Digestive tract acute haemorrhage has been recognized as one of the major risk factors in mortality of surgical patients. A group of 68 elderly ICU patients with non-traumatic haemorrhagic shock (aged 65-95 yrs) was observed. The patients were evaluated according to commonly used severity-of-illness scoring systems: SAPS2, LODS and POSSUM. A retrospective analysis was based on two groups: a) survivors, and b) nonsurvivors. In both groups there was calculated predicted death rate (PDR): on hospital admittance (in SAPS 2 22.3 in survivors vs 34.8 in non-survivors, in LODS 17.4 vs 30.6, respectively), 2 hrs after surgery (in SAPS 2 25.1 in survivors vs 62.3 in non-survivors, in LODS 21.4 vs 57.2, and in POSSUM 61,6 vs 85.4, respectively), and after the first day of ICU treatment (in SAPS 2 35.0 in survivors vs 70.2 in non-survivors, in LODS 32.5 vs 58.2 respectively); p<001. Similarly, numbers of collected points in Therapeutic Intervention Scoring system (TISS-28) were statistically significant between the groups: 36.1 in survivors vs 47.1 in non-survivors, and in TISS-76: 34.0 vs 45.1, respectively p<0.001. The difference was also noticed during collecting points in severity scoring systems: MODS and SOFA; a number of collected points was twice higher when measured after the surgery, than when comparing the MODS and SOFA values, calculated on hospital admittance in non-survivor group.

[Hemorrhagic shock].

Hemorrhagic shock is a condition produced by rapid and significant loss of blood which lead to hemodynamic instability, decreases in oxygen delivery, decreased tissue perfusion, cellular hypoxia, organ damage and can be rapidly fatal. Despite improved understanding of the pathophysiology and significant advances in technology, it remains a serious problem associated with high morbidity and mortality. Early treatment is essential but is hampered by the fact that signs and symptoms of shock appear only after the state of shock is well establish and the compensatory mechanisms have started to fail. The primary goal is to stop the bleeding and restore the intravascular volume. This review addresses the pathophysiology and treatment of haemorrhagic shock.

[Shotgun injuries--epidemiological and clinical aspects]. / Obrazenia ciala w nastepstwie postrzalów--aspekty epidemiologiczne i kliniczne.

Shotgun injuries constitute an increasing surgical problem as they frequently lead to severe trauma disease and even to death. These injuries are mainly diagnosed in young people and are localized in limbs. Human life is in danger in case of shotgun injuries of the head (CNS), abdominal and thoracic cavities. Prognosis is worse in multiple shotgun lesions. The dominating cause of death in shotgun victims is hemorrhagic shock. Patient's life is potentially in a real danger and necessitates precise diagnostic and therapeutic management in the early stages following shotgun trauma, in the operating room and in the postoperative phase.

Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making.

Grading of the clinical status in patients with multiple trauma is important regarding the treatment plan. In recent years, 4 different clinical conditions have been described: stable, borderline, unstable, in extremis. Clinical parameters have been widely used in patients with penetrating injuries, and 3 categories were found to be important: shock, hypothermia, coagulopathy. However, in blunt trauma patients, the role of conventional parameters for decision making regarding the timing of fracture treatment is poorly described. After blunt trauma, additional factors seem to play a role, because the injuries affect multiple body regions. These additional factors are summarized under the term, "soft-tissue injuries," which may include the soft tissues of the extremities, lung, abdomen, and pelvis. The study describes four pathophysiologic cascades that are relevant to the clinical conditions listed above. Threshold values for separation of the patient conditions are documented, leading to a staged surgical strategy.

Endothelial oxidative stress induced by serum from patients with severe trauma hemorrhage.

OBJECTIVE: Shock induces oxidative stress by ischemia-reperfusion phenomenon. Endothelial cells are involved in the inflammatory response and oxidative stress responsible for microcirculation impairment and organ failure. We examined the potential of serum from patients to induce in vitro reactive oxygen species production by cultured human umbilical vein endothelial cells (HUVECs). PATIENTS: Three groups were compared: hemorrhagic shock trauma patients, isolated brain injured patients, and healthy volunteers. METHODS: In the hemorrhagic shock group we sought a correlation between reactive oxygen species production and severity of shock. Serum was separated and perfused in an in vitro model of perfused HUVECs. Ex vivo reactive oxygen species production was assessed by fluorescence microscopy using dichlorodihydrofluorescein, an intracellular dye oxidized by H2O2. Results are expressed in proportional change from baseline and normalized by protidemia to control for variation related to hemodilution. RESULTS: Reactive oxygen species production by endothelial cells exposed to serum from hemorrhagic shock patients (46.2+/-24.9%) was significantly greater than in those with brain injury (3.9+/-35.1%) and in healthy volunteers (-6.8+/-5.8%). In the hemorrhagic shock group dichlorodihydrofluorescein fluorescence was strongly correlated positively to Simplified Acute Physiology Score II and lactatemia and negatively to [HCO3-]. CONCLUSIONS: Serum from trauma patients with hemorrhagic shock induces reactive oxygen species formation in naive endothelial cells which is correlated to shock severity.

Holistic care: treatment and interventions for hypovolemic shock secondary to hemorrhage.

Hypovolemic shock can be a life-threatening condition. This article uses a case study to present the diagnostic criteria and the medical and nursing management of a patient with hypovolemic shock.

[Pre-clinical management of shock patients]. / Präklinische Versorgung des Patienten mit Schock.

The preclinical diagnosis of shock is still based on the patient's history, the physical examination, the injury pattern and a few hemodynamic parameters available in the emergency set-up. The clinical picture is characterised by hypotension and tachycardia, tachypnoe and dyspnoea as well as cerebral impairment. Results from recent clinical trials indicate, that a adapted and specific therapeutic approach for the various shock forms is necessary. In case of traumatic hypovolemic-hemorrhagic shock it is of particular relevance if penetrating trauma and/or uncontrolled bleeding exists. Under these conditions an immediate definite surgical treatment is required ("scoop and run") and a moderate hypotension should be tolerated. ("treat and run"). Fluid substitution and therapy with catecholamines should be used conservatively. In all other forms of shock the treatment approach can and should be more aggressive in order to improve microvascular perfusion as early as possible. Besides adequate fluid resuscitation in a combination of crystalloid and colloid solutions catecholamines and-under specific circumstances-also vasopressin should be used. Of utmost importance in the pre-clinical management of patients in shock is the optimal selection of the centre that the patient is referred to in order to establish the fastest and best possible definite treatment for the patient.

The lack of association between femoral shaft fractures and hypotensive shock.

A retrospective review of all patients with femur fractures was performed to determine whether isolated femoral shaft fractures were associated with hypotensive shock. One hundred patients were identified who had either an isolated femoral shaft fracture (group F, 62 patients) or a femoral shaft fracture in addition to other non-shock producing fractures or minor injuries (group A, 38 patients). No patients in this study were in class III or IV (hypotensive) shock; however, 11% progressed from no shock to class I and 13% from class I to class II. Logistic regression showed no association between class II shock and age, sex, or weight. The presence of additional fractures (p = 0.004) and total fluids received from fracture to stabilization (p = 0.014) had a highly significant association with class II shock in a joint analysis. Mechanism of injury, although significant as an independent variable, was highly associated with the presence of additional fractures and so is not required in the joint model. Femur fractures alone or in combination with other minor injuries should not be considered the cause of hypotensive shock in the traumatized patient. In the traumatized patient who presents with a closed femoral shaft fracture and hypotension, an alternative source of hemorrhage should be sought.