RESUMEN
This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.
RESUMEN
Precise, efficient, and effective control of chemical reaction conditions is a viable measure for the environment-conscious time and energy resource management in modern laboratories and in industry. Parameter changes such as surface enlargement, pH, local reactant accumulation by solvent evaporation and polarization effects, etc., have been shown to greatly affect the reaction rate of a chemical reaction. In electrospray (ES) ionization - a soft ionization method often used for mass spectrometry - all these parameters change constantly and with high dynamics during the nebulization process that generates droplets as the ultimate confined µ-reaction vessels. Therefore, high acceleration factors are reported in literature for a manifold of such µ-droplet reactions. Here, the tri-molecular Mannich reaction was identified as a suitable candidate for studying thermal, electronic, and fluidic manipulation of the ES process to achieve high conversion rates with short reaction times and compare them to the batch reaction. Some of these manipulations were conducted separately to better quantify their individual contributions. Here, the keto-enol-tautomerism of the used ß-diketones, the high proton concentrations, and the longer reaction times in the µ-droplets are presumed to have the greatest impact on these enhancement factors. Experiments were performed to find ES conditions with small initial droplets and long droplet flight times where the highest reaction conversion rates are obtained. A sharp increase in the product peak was found at large distances between the mass spectrometry (MS) inlet and ES source at high voltages. Moreover, different trends were found for the two ketones studied, acetylacetone (AcAc) and 1,3-cyclohexanedione (Cyclo), by changing the temperature of the heated ES source. Finally, high conversion rates were obtained for the combination of formaldehyde (Fal) and piperidine (Pip) with AcAc and Cyclo, respectively, with over 90%. With respect to the batch reaction, this is mainly due to an increase in reaction kinetics as well as a shift in thermodynamics for the µ-droplet reaction environment.
