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10/04/2021

Ketamine: Le point US

Ketamine Use in Operation Enduring Freedom

Leslie E. et al. Mil Med 2021 Apr 7;usab117. doi: 10.1093/milmed/usab117

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La Kétamine fait partie maintenant de l'arsenal thérapeutique utilisé par les US. Dans la discussion l'article évoque une probable sous déclaration d'emploi lié à un système de recueil des données encore à nparfaire au niveau des role 1

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Introduction

Ketamine is a dissociative anesthetic increasingly used in the prehospital and battlefield environment. As an analgesic, it has been shown to have comparable effects to opioids. In 2012, the Defense Health Board advised the Joint Trauma System to update the Tactical Combat Casualty Care Guidelines to include ketamine as an acceptable first line agent for pain control on the battlefield. The goal of this study was to investigate trends in the use of ketamine during Operation Enduring Freedom (OEF) and Operation Freedom’s Sentinel (OFS) during the years 2011-2016.

Materials and Methods

A retrospective review of Department of Defense Trauma Registry (DoDTR) data was performed for all patients receiving ketamine during OEF/OFS in 2011-2016. Prevalence of ketamine use, absolute use, mechanism of injury, demographics, injury severity score, provider type, and co-administration rates of various medications and blood products were evaluated.

Results

Total number of administrations during the study period was 866. Ketamine administration during OEF/OFS increased during the years 2011-2013 (28 patient administrations in 2011, 264 administrations in 2012, and 389 administrations in 2013). A decline in absolute use was noted from 2014 to 2016 (98 administrations in 2014, 41 administrations in 2015, and 46 administrations in 2016). The frequency of battlefield ketamine use increased from 0.4% to 11.3% for combat injuries sustained in OEF/OFS from 2011 to 2016. Explosives (51%) and penetrating trauma (39%) were the most common pattern of injury in which ketamine was administered. Ketamine was co-administered with fentanyl (34.4%), morphine (26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma (10.3%), and packed red blood cells (18.5%).

Conclusions

This study demonstrates increasing use of ketamine by the U.S. Military on the battlefield and effectiveness of clinical practice guidelines in influencing practice patterns.

14/03/2021

Hydrazine: Qu'est ce que c'est ?

The Toxicity, Pathophysiology, and Treatment of Acute Hydrazine Propellant Exposure: A Systematic Review

Nguyen HN et Al. Mil Med. 2021 Feb 26;186(3-4):e319-e326. 

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L'hydrazine est employé comme combustible dans les fusées et dans les F16 américains en tant que combustible alimentant une unité de puissance de secours. Et cela n'est pas sans conséquence lors d'une intervention auprès d'un tel type d'aéronef.

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Introduction:

Hydrazines are highly toxic inorganic liquids that are used as propellants in military and aviation industries, such as the U.S. Air Force F-16 Emergency Power Unit and SpaceX SuperDraco Rockets. The most commonly used derivatives include hydrazine, monomethylhydrazine, and 1,1-dimethylhydrazine (unsymmetrical dimethylhydrazine). Industrial workers in close contact with hydrazines during routine maintenance tasks can be exposed to levels well above the National Institute for Occupational Safety and Health relative exposure limits.

Materials and methods: A systematic review was performed using PubMed, Web of Science, Google Scholar, National Aeronautics and Space Administration Technical Server, and Defense Technical Information Center, and data related to hydrazine exposures were searched from inception to April 2020. Publications or reports addressing hydrazine toxicity, pathophysiology, and treatment of hydrazine fuel exposure were selected.

Results: Acute toxic exposures to hydrazine and its derivatives are rare. There are few case reports of acute toxic exposure in humans, and data are largely based on animal studies. The initial search identified 741 articles, manuscripts, and government reports. After screening for eligibility, 51 were included in this review. Eight articles reported acute exposures to hydrazine propellant in humans, and an additional 14 articles reported relevant animal data.

Conclusions: Exposure to small amounts of hydrazine and its derivatives can cause significant soft tissue injury, pulmonary injury, seizures, coma, and death. Neurologic presentations can vary based on exposure compound and dose. Decontamination is critical as treatment is mainly supportive. High-dose intravenous pyridoxine has been suggested as treatment for hydrazine-related neurologic toxicity, but this recommendation is based on limited human data. Despite recent research efforts to generate less toxic alternatives to hydrazine fuel, it will likely continue to have a role in military and aviation industries. Aerospace and military physicians should be aware of the toxicity associated with hydrazine exposure and be prepared to treat hydrazine toxicity in at-risk populations.

02/02/2021

TXA: Oui, mais parfois pas nécessaire

Unjustified Administration in Liberal Use of Tranexamic Acid in Trauma Resuscitation

Tareq Kheirbek T et Al. J Surg Res . 2021 Feb;258:125-131. doi: 10.1016/j.jss.2020.08.045.

Background:

Early administration of tranexamic acid (TXA) has been widely implemented for the treatment of presumed hyperfibrinolysis in hemorrhagic shock. We aimed to characterize the liberal use of TXA and whether unjustified administration was associated with increased venous thrombotic events (VTEs).

Methods:

We identified injured patients who received TXA between January 2016 and January 2018 by querying our Level 1 trauma center's registry. We retrospectively reviewed medical records and radiologic images to classify whether patients had a hemorrhagic injury that would have benefited from TXA (justified) or not (unjustified).

Results:

Ninety-five patients received TXA for traumatic injuries, 42.1% were given by emergency medical services. TXA was considered unjustified in 35.8% of the patients retrospectively and in 52% of the patients when given by emergency medical services. Compared with unjustified administration, patients in the justified group were younger (47.6 versus 58.4; P = 0.02), more hypotensive in the field (systolic blood pressure: 107 ± 31 versus 137 ± 32 mm Hg; P < 0.001) and in the emergency department (systolic blood pressure: 97 ± 27 versus 128 ± 27; P < 0.001), and more tachycardic in emergency department (heart rate: 99 ± 29 versus 88 ± 19; P = 0.04). The justified group also had higher injury severity score (median 24 versus 11; P < 0.001), was transfused more often (81.7% versus 20.6%; P < 0.001), and had higher in-hospital mortality (39.3% versus 2.9%; P < 0.001), but there was no difference in the rate of VTE (8.2% versus 5.9%).

Conclusions:

Our results highlight a high rate of unjustified administration, especially in the prehospital setting. Hypotension and tachycardia were indications of correct use. Although we did not observe a difference in VTE rates between the groups, though, our study was underpowered to detect a difference. Cautious implementation of TXA in resuscitation protocols is encouraged in the meantime. Nonetheless, adverse events associated with unjustified TXA administration should be further evaluated

08/12/2020

Lidocaïne IV: Cette oubliée

The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety

Foo I. et Al. Anaesthesia  . 2020 Nov 3. doi: 10.1111/anae.15270.

anae.v75.12.cover.jpg

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28/11/2020

Kétamine: Recommendations de l'ACEP

Keta.jpg

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| Tags : kétamine

15/11/2020

Solutés hypersalés: Sûrs pour la coagulation

The effect of hypertonic saline and mannitol on coagulation in moderate traumatic brain injury patients

Wang H et Al. Am J Emerg Med. 2017 Oct;35(10):1404-1407

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Du moins pour le salé à 3%, administré ici pendant 3 jours.

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Background:

Hyperosmolar therapy, using either hypertonic saline (HTS) or mannitol (MT), is considered the treatment of choice for intracranial hypertension, a disorder characterized by high intracranial pressure (ICP). However, hyperosmolar agents have been postulated to impair coagulation and platelet function. The aim of this study was to identify whether HTS and MT could affect coagulation in moderate traumatic brain injury (TBI) patients.

Methods: In this prospective and randomized double-blind study, we included adult patients with moderate TBI. Patients were divided into two groups according to the type of hypertonic solution administered. Group A patients received 20% MT and group B patients received 3% HTS. Rotational thromboelastometry (ROTEM) parameters were used to assess coagulation and platelet function.

Results:

ROTEM parameters included CT (clotting time), CFT (clot formation time), maximum clot firmness (MCF) measured by MCF (EXTEM and INTEM), MCF (FIBTEM) and standard coagulation tests (p>0.05). No significant differences were found between the two groups. Moreover, ROTEM parameters did not show significant changes at different time points after administration of the hyperosmolar solutions (p>0.05).

Conclusions: Overall, use of 3% HTS and 20% MT for the control of ICP did not significantly affect patients' coagulation function. Therefore, hyperosmotic solution is safe and does not increase the risk of intracranial rebleeding.

11/11/2020

Inhibition de l'histone déacetylsae pour l'hémorragie

Histone deacetylase 6 inhibition improves survival in a swine model of lethal hemorrhage, polytrauma, and bacteremia

Biesterveld  BE et Al.  J Trauma Acute Care Surg . 2020 Nov;89(5):932-939.

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Le TXA fait partie de l'arsenal thérapeutique en cas d'hémorragie sévère d'origine traumatique. Cela pourrait être également le cas des inhibiteurs de l'histone déacétylsae, famille de l'acide valproïque - Dépakine-

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Background: Trauma is the leading cause of death for young Americans. Nonspecific histone deacetylase inhibitors, such as valproic acid, have been shown to improve survival in preclinical models of lethal trauma, hemorrhage, and sepsis. The doses needed to achieve a survival benefit are higher than Food and Drug Administration-approved doses, and the nonspecificity raises concerns about unintended adverse effects. The isoform-specific histone deacetylase 6 inhibitor, ACY-1083, has been found to be as efficacious as valproic acid in a rodent model of hemorrhagic shock. We hypothesized that ACY-1083 treatment would improve survival in a swine model of lethal hemorrhage, polytrauma, and bacteremia.
Methods: Swine were subjected to 45% blood volume hemorrhage, brain injury, femur fracture, rectus crush, splenic and liver lacerations, and colon injury. After 1 hour of shock (mean arterial pressure, 30-35 mm Hg), animals were randomized to normal saline resuscitation (control) or normal saline plus ACY-1083 30 mg/kg treatment (n = 5/group). After 3 hours (simulating delayed evacuation), packed red blood cells and antibiotics were administered, the colon injury was repaired, and the abdomen was closed. Animals were then monitored for another 4 hours. Survival was assessed using Kaplan-Meier and log-rank test.
Results: This combination of injuries was lethal. All animals became bacteremic, in addition to the severe hemorrhagic shock. Survival in the control group was 0%, and ACY-1083 treatment increased survival to 80% (p = 0.019). There was no difference in the brain lesion size between the groups.
Conclusion: A single dose of ACY-1083 markedly improves survival in an otherwise lethal model of polytrauma, hemorrhagic shock, and bacteremia.

22/10/2020

Albumine: Le retour ?

Should Albumin be Considered for Prehospital Resuscitation in Austere Environments? A Prospective Randomized Survival Study in Rabbits

Kheirabadi BS et Al. Shock . 2020 Sep;54(3):358-367.

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Le remplissage vasculaire par albumine diluée n'est pas spécialement recommandé. Pourtant il semblerait que cela soit à tort dans certains environnements. C'est du moins ce que laisse penser ce travail expérimental chez le lapin.

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Background:

The new guidelines for prehospital care of combat casualties in shock recommend administration of whole blood or blood components to increase blood pressure to a permissible hypotensive level (i.e., hypotensive resuscitation [HR]). We investigated if 2 h of HR using limited volumes of whole blood, plasma, or albumin would lead to full recovery and long-term survival of rabbits subjected to severe hemorrhagic shock (HS).

Methods:

Following instrumentation, laparotomy was performed on IV-anesthetized spontaneously breathing New Zealand white rabbits (3.0 kg -3.5 kg). Next, ∼40% of rabbits' blood volume was removed producing HS (mean arterial pressure [MAP]∼20 mm Hg). Fifteen minutes later, rabbits were resuscitated with a limited volume (12.5 mL/kg) of rabbit whole blood (fresh whole blood [FWB]), rabbit fresh frozen plasma (FFP), or 5% human albumin (ALB) to a target pressure (MAP) of 60 mm Hg (n=8/grp) and monitored for 2 h. Liver bleeding time was measured at baseline and 10 min after HR. Subsequently, animals were fully resuscitated (blood + lactated Ringer [LR]), surgically repaired, and recovered for 8 days. An untreated group (n = 6) was also included.

Results:

Following HS, lactate and base deficit levels were increased to 8.2 ± 1.6 and 12.9 ± 3.1 mM respectively with no difference among groups. A lower volume of FWB volume was required to reach the target MAP (P < 0.05 vs. ALB) but MAP declined during the HR period (P < 0.01 vs. ALB).

image_2020-10-22_214840.png

FWB provided higher hematocrit and platelets but it did not reduce lactate level faster than other fluids. Beside higher fibrinogen, no differences were found in hemostatic or resuscitative effects of FFP versus ALB. Bleeding time was prolonged with ALB and FFP fluids but unchanged with FWB. Untreated rabbits died during shock or shortly after. All treated rabbits except one recovered and lived for 8 days with normal blood tests and similar tissue histology.

Conclusions:

Two hours of HR using a limited volume of FWB, FFP, or ALB led to full recovery and long-term survival of rabbits subjected to HS. Apart from bleeding time, no clinically significant differences were found among the three fluids. Five percent human albumin solutions are isotonic, iso-oncotic, ready-to-use, stable, and compatible with all blood types and should be considered for prehospital resuscitation where blood products are not available or not accepted.

| Tags : remplissage

12/03/2020

Vasopresseurs: Pas si bon ?

Prehospital vasopressor use is associated with worse mortality in combat wounded.

 

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Le recours à un vasopresseur est recommandé lors de la prise en charge du choc hémorragique. Le travail présenté qui porte sur le choc traumatique du blessé de guerre ne semble pas être en faveur de cette recommandation. Ceux recevant un vasopressueurs auraient une mortalité plus élevée. Ces résultats sont à prendre avec recul tant la fréquence de l'emploi de soutien hémodynamique apparait faible (0,4% des blessés) et de l'absence de données sur la temporalité de l'administration des vasopresseurs. De plus il semble exister une différence dans les mécanismes d'aggression (plus d'explosion dans le groupe avec soutien). Les auteurs évoquent l'intérêt de la vasopressine dont l'apport serait meilleur que celui de la noradrénaline et de l'adrénaline

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Introduction:

Vasopressor medications are frequently used in the management of hypotension secondary to shock. However, little data exists regarding their use in hypotensive trauma patients and their use is controversial.

Methods:

The Department of Defense Trauma Registry was queried from January 2007 to August 2016 using a series of procedural codes to identify eligible casualties, which has been previously described. Mortality was compared between hypotensive casualties with documentation of receipt of vasopressor medications versus casualties not receiving vasopressors. To control for potential confounders, comparisons were repeated by constructing a multivariable logistic regression model including that utilized patient category, mechanism of injury, composite injury severity score, total blood products transfused, prehospital heart rate and prehospital systolic pressure. Survival was compared between these groups using propensity matching.

Results: Our search strategy yielded 28,222 patients, 124 (0.4%) of whom received prehospital vasopressors. On univariable analysis vasopressor use was associated with a lower odds of survival (OR 0.09, 0.06-0.13). The lower odds of survival persisted in the multivariate logistic regression model (OR 0.32, 0.18-0.56). Survival was lower among the vasopressor group (71.3%) when compared to a propensity matched cohort (94.3%).Conclusions: In this dataset, prehospital vasopressor use was associated with lower odds of survival. This finding persisted when adjusting for confounders and in a propensity matched cohort model.

| Tags : choc

03/01/2020

Hydroxocobalamine pour l'hémorragie aussi ?

Intravenous Hydroxocobalamin Versus Hextend Versus Control for Class III Hemorrhage Resuscitation in a Prehospital Swine Model.

Background:

Hydroxyethyl starch (Hextend) has been used for hemorrhagic shock resuscitation, however, hydroxyethyl starch may be associated with adverse outcomes.

Objective:

To compare systolic blood pressure (sBP) in animals that had 30% of their blood volume removed and treated with intravenous hydroxocobalamin, hydroxyethyl starch, or no fluid.

Methods:

Twenty-eight swine (45-55 kg) were anesthetized and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged 20 mL/kg over 20 minutes and then administered 150 mg/kg IV hydroxocobalamin in 180 mL saline, 500 mL hydroxyethyl starch, or no fluid and monitored for 60 minutes. Data were modeled using repeated measures multivariate analysis of variance.

Results:

There were no significant differences before treatment. At 20 minutes after hemorrhage, there was no significant difference in mean sBP between treated groups, however, control animals displayed significantly lower mean sBP (p < 0.001). Mean arterial pressure and heart rate improved in the treated groups but not in the control group (p < 0.02). Prothrombin time was longer and platelet counts were lower in the Hextend group (p < 0.05). Moreover, thromboelastography analysis showed longer clotting (K) times (p < 0.05) for the hydroxyethyl starch-treated group.

Conclusion:

Hydroxocobalamin restored blood pressure more effectively than no treatment and as effectively as hydroxyethyl starch but did not adversely affect coagulation.

17/09/2019

Penthrox: Ne nous emballons pas

Methoxyflurane in Pre-Hospital Settings: A Review of Clinical Effectiveness, Cost-Effectiveness and Guidelines

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Beaucoup d'intérêt pour cet agent  tombé en désuétude en anesthéise du fait d'effets secondaires importants  mais utilisé comme antalgique. La HAS a émis un avis pour le moin mitigé. C'est également la position de l'agence du médicament canadienne qui reconnait des effets antalgiques réel mais sans avantage vrai par rapport à la morphine dans le domaine pré-hospitalier.

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The objective of this review is to evaluate the clinical effectiveness, cost-effectiveness, and evidence-based guidelines for the use of low-dose methoxyflurane for the management of moderate to severe pain associated with trauma or procedures in the pre-hospital setting.

29/07/2019

Penthrox: Risque d'hyperthermie maligne ?

An in-vitro model of malignant hyperthermia: differential effects of inhalation anesthetics on caffeine-induced muscle contractures.

 
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L'engouement en médecine d'urgence pour l'emploi du penthrox (1) se justifie notamment par sa simplicité de mise en oeuvre et la très grande rapidité d'obtention d'une analgésie qui reste cependant modérée (2). Cependant la HAS n'a pas retrouvé d'amélioration du service rendu pour cet agent d'anesthésie ancien. Dans les diverses publications, il n'est pratiquement jamais abordé le sujet du déclenchement d'une crise d'hyperthermie maligne. Pourtant cet agent est un agent déclencheur presqu'aussi "efficace" que l'halothane. Cette vieille publication l'atteste. Cceci étant dit il faut relativiser ce risque qui parait également dose dépendant sans que l'on sache bien à quel niveau se situe le seuil déclenchant (3) .
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Clinical concentrations of anesthetics augment caffeine-induced contracture of frog sartorius muscle; however, anesthetics differ in this characteristic. The potentiation was quantitated using six paired sartorius muscles for each specified concentration of anesthetic and controls. At a concentration of 1 MAC, the greatest potentiation occurred with 2 mM caffeine for all anesthetics studied. Under these conditions the order of magnitude of augmentations was: chloroform (15 times); halothane (11 times); methoxyflurane (10 times); cyclopropane (5 times); enflurane (4 times); isoflurane (3 times); diethyl ether (2 times); Baxter 3224 (2 times); fluroxene (1.4 times); nitrous oxide (1.3 times).

HTMA Methoxy.jpeg

Halothane at .5 MAC augments the 2 mM caffeine-induced contracture almost seven times, and at 2 MAC almost 13 times, whereas 2 MAC isoflurane potentiates the caffeine-induced contracture only four times and 4 MAC diethyl ether only two and a half times. It is postulated that those anesthetics that most potentiate caffeine-induced contracture may be the most potent triggering agents of malignant hyperthermia.

18/07/2019

ISR chez le traumatisé: Etomidate toujours pas convaincant

Pre-hospital emergent intubation in trauma patients: the influence of etomidate on mortality, morbidity and healthcare resource utilization.

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Cette publication revient sur le débat qui porte sur l'emploi de l'étomidate pour l'intubation préhospitalière. Son emploi est remis en cause par certains, notamment à cause de ses effets dépresseurs cortico-surrénaliens tout particulièrement en cas de sepsis. Les auteurs,  si ils ne rapportent pas d'effets délétères sur la mortalité, mettent en évidence une durée d'hospitalisation et de ventialtion plus longue dans le groupe ETO. Plusieurs informations méritent une lecture critique de ce travail. Le premier est la présence dans le groupe non-ETO de thiopental, responsable de nombreux décès lors de l'attaque de pearl harbour (1). La seconde est l'augmentation significative de défaillance cardio-vasculaire dan le groupe non-ETO. On peut se poser la question de l'impact du thiopental dans ce groupe. Le propofol peut également être à l'origine d'une instabilité hémodynamique et nécessite un vrai apprentissage. La quatrième réflexion porte sur le niveau de qualification, qui n'est pas précisé, des personnels réalisant ces intubations.

Ce document ne permet pa de remettre en question la recommandation d'emploi de la Kétamine pour l'ISR dans le cadre de la mise en condition de survie du blessé de guerre (2).

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 BACKGROUND:

Due to its favorable hemodynamic characteristics and by providing good intubation conditions etomidate is often used for induction of general anesthesia in trauma patients. It has been linked to temporary adrenal cortical dysfunction. The clinical relevance of this finding after a single-dose is still lacking appropriate evidence.

METHODS:

This retrospective multi-centre study is based on merged data from a German Helicopter Emergency Medical Service (HEMS) database and a large trauma patient registry. All trauma patients who were intubated prior to hospital admission with a documented Injury Severity Score ≥ 9 between 2008 and 2012 were eligible for analysis. The primary endpoint was hospital mortality. Other outcome measures were organ failures, sepsis, length of ventilation, as well as length of stay in hospital and ICU.

RESULTS:

One thousand six hundred ninety seven patients were enrolled into the study. Seven hundred sixty two patients received etomidate and 935 patients received other induction agents. The in-hospital mortality was similar in both groups (18.9% versus 18.2%; p = 0.71). Incidences of organ failures and sepsis were not increased in the etomidate group. However, health care resource utilization parameters were prolonged (after adjusting: + 1.3 days for ICU length of stay, p = 0.062; + 0.8 days for length of ventilation, p = 0.15; + 2,7 days for hospital length of stay, p = 0.034). A multivariable logistic regression analysis did not identify etomidate as an independent predictor of hospital mortality (OR: 1.10, 95% CI: 0.77-1.57; p = 0.60).

CONCLUSIONS:

This is the largest trial investigating outcome data for trauma patients who had received a single-dose of etomidate for induction of anesthesia. The use of etomidate did not affect mortality. The influence on morbidity and health care resource utilization remains unclear.

| Tags : etomidate, intubation

09/04/2019

Substituts au sang: Ils arrivent !

Artificial oxygen carriers- past, present and the future-a review of the most innovative and clinically relevant concepts.

Ferenz KB et Al. J Pharmacol Exp Ther. 2019 Mar 5. pii: jpet.118.254664. doi: 10.1124/jpet.118.254664.

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La question du transport de l'oxygène est fondamentale pour le traumatisé sévère. La recherche de transporteurs artificiels d'oxygène sont un axe fondamental de la recherche. Il se trouve qu'une entreprise bretonne fait partie des quelques équipes travaillant sur le sujet (voir ici)

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Blood transfusions are daily practice in hospitals. As these products are limited in availability and have various, harmful side-effects, researchers have pursued the goal to develop artificial blood components for about 40 years. Development of oxygen therapeutics and stem cells are more recent goals. Medline, clinicaltrials.gov, clinicaltrialsregister.eu and ANZCTR were searched up to November 2017 using search terms related to artificial blood products to identify new and ongoing research of the last 5 years. For already well-known products that are, however, important to the field or relevant to gain a better understanding, the reader is punctually referred to some important articles older than 5 years. This review includes not only clinically relevant substances such as heme-oxygenating carriers (HBOCs), PFOCs, stem cells and organ conservation, but also interesting pre-clinically advanced compounds depicting the pipeline of potential new products. In- depths insights into specific benefits and limitations of each substance, including the biochemical and physiological background are included. "Fancy" ideas such as Iron-based substances, O2-microbubbles, cyclodextranes or lugworms are also elucidated. To conclude, this systematic up-to-date review includes all actual achievements and ongoing clinical trials in the field of artificial blood products to pursue the dream of artificial oxygen carrier supply. Research is on the right track, but the task is demanding and challenging.

Lire aussi

05/04/2019

ISR: Ket/Celo SANS autre chose

Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review

01/04/2019

Oxsealife: LE cristalloïde de demain ?

The effect of a novel intravenous fluid (Oxsealife®) on recovery from haemorrhagic shock in pigs.
 

 

Blood transfusion is given according to haemoglobin thresholds aimed at restoration of arterial oxygen-carrying capacity. Patient survival after severe haemorrhagic shock depends on restoration of microvascular perfusion, tissue oxygen delivery, endothelial function and organ integrity. We investigated a novel crystalloid fluid designed for tissue oxygen delivery, Oxsealife® , with components that generate microvascular nitric oxide and scavenge reactive oxygen species generated during ischaemia-reperfusion injury. The amount of dissolved oxygen in blood progressively increased during step-wise in vitro haemodilution with this fluid, suggesting that the oxygen solubility coefficient of blood is dynamic, not static. We performed a pilot safety and efficacy study to compare resuscitation with this novel crystalloid vs. whole blood transfusion in a swine haemorrhagic shock model with animals bled to an arterial lactate oxygen debt target. Despite contributing no haemoglobin, viscosity nor oncotic potential, resuscitation with Oxsealife after severe haemorrhagic shock restored central haemodynamic parameters comparable to stored allogeneic blood transfusion. Tissue perfusion, oxygenation and metabolic outcomes were equivalent between treatment groups. Increased consumption of bicarbonate in animals given Oxsealife suggested greater capillary recruitment and enhanced clearance of acidic tissue metabolites. Serum markers of organ function, animal activity during recovery and histological analysis of tissue morphology and endothelial glycocalyx integrity confirmed functional recovery from haemorrhagic shock. We conclude that recovery of tissue oxygen delivery and organ function after haemorrhagic shock may not be dependent on treatments that increase haemoglobin levels. Oxsealife shows promise for treatment of severe haemorrhagic shock and may reduce the requirement for allogeneic blood products.

16/01/2019

Plyo prehospitalier: N'améliore pas la survie ?

The impact of prehospital administration of freeze-dried plasma on casualty outcome.

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Ce travail qui porte sur l'étude de l'impact, chez des blessés en choc hémorragique,  de la perfusion préhospitalière de PLyo confirme son intérêt en terme d'économie transfusionnelle mais pas en terme de mortalité. Les auteurs mettent en avant la taille de leur cohorte de blessés pour expliquer ce résultat négatif. On notera également les délais courts de transport.
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BACKGROUND:

Hemorrhage is the most common preventable cause of death in both civilian and military trauma. There is no consensus regarding the appropriate fluid resuscitation protocol. Plasma, as a resuscitative fluid, has substantial benefits as a volume expander, owing to its relatively high oncotic pressure and its positive effect on trauma-induced coagulopathy by replenishing the lost coagulation factors, rather than diluting the casualty's remaining factors. The Israel Defense Force Medical Corps decided to use freeze-dried plasma (FDP) as the fluid of choice for casualties in hemorrhagic shock in the prehospital setting. The aim of our study is to compare the differences of coagulation, perfusion measurements, resource utilization, and outcome between casualties receiving FDP to casualties who did not receive FDP in the prehospital setting.

METHODS:

This is a retrospective matched cohort study based on two groups of casualties (those treated with FDP vs. those without FDP treatment). The control group was compiled in three steps of precision for age, sex, mechanism of injury and maximum level of severity for each nine injured body regions. Data were collected from the IDF Trauma Registry and The National Israel Trauma Registry.

RESULTS:

The study group comprised 48 casualties receiving FDP and 48 controls with no differences in demographic, evacuation time, and injury characteristics. The FDP group demonstrated a lower level of hemoglobin (12.7 gr/dzl) (odds ratio [OR], 3.11; 95% confidence interval [CI], 1.10-8.80), lower level of international normalized ratio (1.1) (OR, 3.09; 95% CI, 1.04-9.14), and lower level of platelets (230 × 109/L) (OR, 3.06; 95% CI, 1.16-8.06). No other differences were found between the two groups.

 

" In the total study population, seven (7.3%) casualties died in hospital, among which 8.3% were from the FDP group, compared with 6.2% from the control group"

CONCLUSION:

The use of FDP in the prehospital setting has logistic benefits and a positive effect on coagulation profile, with no other significant effects. Future studies need to be performed on larger groups to verify trends or nullify our hypotheses.

 

08/01/2019

TXA à l'avant: Peut être pas si simple !

Prehospital Tranexamic Acid Administration During Aeromedical Transport After Injury.

Boudreau RM et Al. J Surg Res. 2019 Jan;233:132-138
 
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Un article de plus qui doit faire interroger sur l'intérêt réel du TXA, notamment son administration quai systématique à l'avant et pointe la réalité des complications thrombo-emboliques. Une plus grande sélectivité dans les critères d'administration est discutée.
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BACKGROUND:

Tranexamic acid (TXA) has been shown to reduce mortality in the treatment of traumatic hemorrhage. This effect seems most profound when given early after injury. We hypothesized that extending a protocol for TXA administration into the prehospital aeromedical setting would improve outcomes while maintaining a similar safety profile to TXA dosed in the emergency department (ED).

MATERIALS AND METHODS:

We identified all trauma patients who received TXA during prehospital aeromedical transport or in the ED at our urban level I trauma center over an 18-mo period. These patients had been selected prospectively for TXA administration using a protocol that selected adult trauma patients with high-risk mechanism and concern for severe hemorrhage to receive TXA. Patient demographics, vital signs, lab values including thromboelastography, blood administration, mortality, and complications were reviewed retrospectively and analyzed.

RESULTS:

One hundred sixteen patients were identified (62 prehospital versus 54 ED). Prehospital TXA patients were more likely to have sustained blunt injury (76% prehospital versus 46% ED, P = 0.002). There were no differences between groups in injury severity score or initial vital signs.

TXA.jpeg

There were no differences in complication rates or mortality. Patients receiving TXA had higher rates of venous thromboembolic events (8.1% in prehospital and 18.5% in ED) than the overall trauma population (2.1%, P < 0.001).

CONCLUSIONS:

Prehospital administration of TXA during aeromedical transport did not improve survival compared with ED administration. Treatment with TXA was associated with increased risk of venous thromboembolic events. Prehospital TXA protocols should be refined to identify patients with severe hemorrhagic shock or traumatic brain injury.

 

30/12/2018

HEXACYL: Oui , mais attention à la MTE

Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism.

 

BACKGROUND:

Tranexamic acid (TXA) is used as a hemostatic adjunct for hemorrhage control in the injured patient and reduces early preventable death. However, the risk of venous thromboembolism (VTE) has been incompletely explored. Previous studies investigating the effect of TXA on VTE vary in their findings. We performed a propensity matched analysis to investigate the association between TXA and VTE following trauma, hypothesizing that TXA is an independent risk factor for VTE.

METHODS:

This retrospective study queried trauma patients presenting to a single Level I trauma center from 2012 to 2016. Our primary outcome was composite pulmonary embolism or deep vein thrombosis. Mortality, transfusion, intensive care unit and hospital lengths of stay were secondary outcomes. Propensity matched mixed effects multivariate logistic regression was used to determine adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) of TXA on outcomes of interest, adjusting for prespecified confounders. Competing risks regression assessed subdistribution hazard ratio of VTE after accounting for mortality.

RESULTS:

Of 21,931 patients, 189 pairs were well matched across propensity score variables (standardized differences <0.2). Median Injury Severity Score was 19 (interquartile range, 12-27) and 14 (interquartile range, 8-22) in TXA and non-TXA groups, respectively (p = 0.19). Tranexamic acid was associated with more than threefold increase in the odds of VTE (aOR, 3.3; 95% CI, 1.3-9.1; p = 0.02).

TXA.jpg

Tranexamic acid was not significantly associated with survival (aOR, 0.86; 95% CI, 0.23-3.25; p = 0.83). Risk of VTE remained elevated in the TXA cohort despite accounting for mortality (subdistribution hazard ratio, 2.42; 95% CI, 1.11-5.29; p = 0.03).

CONCLUSION:

Tranexamic acid may be an independent risk factor for VTE. Future investigation is needed to identify which patients benefit most from TXA, especially given the risks of this intervention to allow a more individualized treatment approach that maximizes benefits and mitigates potential harms.

| Tags : coagulopathie

19/10/2018

Morphine pour le blessé ? Un risque faible

Opioid analgesia on the battlefield: a retrospective review of data from Operation HERRICK.

Lewis P et Al. J R Army Med Corps. 2018 Sep;164(5):328-331.

BACKGROUND:

Acute pain secondary to trauma is commonly encountered on the battlefield. The use of morphine to manage pain during combat has been well established since the 19th century. Despite this, there is relatively little research on analgesia use in this environment. This study aims to review the use and complications of morphine and other opioids during Operation HERRICK.

 

METHODS: A database search of the Joint Theatre Trauma Registry was completed looking for all incidences of morphine, fentanyl or naloxone use from February 2007 to September 2014. Microsoft Excel was used to analyse the results.

RESULTS:

Opioid analgesia was administered to 5801 casualties. Morphine was administered 6742 times to 3808 patients. Fentanyl was administered 9672 times to 4318 patients. Naloxone was used 18 times on 14 patients, giving a complication rate of 0.24%. Opioid doses prior to naloxone administration range from 0 to 72 mg of morphine and from 0 to 100 mcg of fentanyl. Four casualties (two local civilians and two coalition forces) received naloxone despite no recorded opioids being administered. Opium abuse was prevalent among the local population in Afghanistan, and this could explain the rationale behind two local national casualties receiving naloxone without any documented opioids being given.

CONCLUSION:

The use of opioids in a battlefield environment is extremely safe. Complication rates are similar to previously published data which is reassuring. The efficacy of different opioids was not covered by this study, and further analysis is required, particularly following the introduction of oral transmucosal fentanyl citrate and the availability of novel non-opioid analgesics.

| Tags : douleur