Shock Injury Research Articles

Elamipretide mitigates ischemia-reperfusion injury in a swine model of hemorrhagic shock

ischemia-reperfusion injury (IRI) after hemorrhage is potentiated by aortic occlusion or resuscitative endovascular balloon occlusion of the aorta (REBOA). Given the central role of mitochondrial injury in shock, we hypothesized that Elamipretide, a peptide that protects mitochondria, would mitigate IRI after hemorrhagic shock and REBOA. Twelve pigs were subjected to hemorrhagic shock and 45 min of REBOA. After 25 min of REBOA, animals received either saline or Elamipretide. Animals were transfused with autologous blood during balloon deflation, and pigs were resuscitated with isotonic crystalloids and norepinephrine for 4.25 h. Elamipretide-treated animals required less crystalloids than the controls (62.5 [50–90] and 25 [5–30] mL/kg, respectively), but similar amounts of norepinephrine (24.7 [8.6–39.3] and 9.7 [2.1–12.5] mcg/kg, respectively). Treatment animals had a significant reduction in serum creatinine (control: 2.7 [2.6–2.8]; Elamipretide: 2.4 [2.4–2.5] mg/dL; p = 0.04), troponin (control: 3.20 [2.14–5.47] ng/mL, Elamipretide: 0.22 [0.1–1.91] ng/mL; p = 0.03), and interleukin-6 concentrations at the end of the study. There were no differences in final plasma lactate concentration. Elamipretide reduced fluid requirements and protected the kidney and heart after profound IRI. Further understanding the subcellular consequences of REBOA and mitochondrial rescue will open new therapeutic avenues for patients suffering from IRI after hemorrhage.

Dexmedetomidine improves acute lung injury by activating autophagy in a rat hemorrhagic shock and resuscitation model

Dexmedetomidine (DEX) can reduce lung injury in a hemorrhagic shock (HS) resuscitation (HSR) model in rats by inhibiting inflammation. Here, we aimed to investigate if these effects of DEX are due to autophagy activation. Therefore, we established HSR rat models and divided them into four groups. HS was induced using a blood draw. The rats were then resuscitated by reinjecting the drawn blood and saline. The rats were sacrificed 24 h after resuscitation. Lung tissues were harvested for histopathological examination, determination of wet/dry lung weight ratio, and detection of the levels of autophagy-related marker proteins LC3, P62, Beclin-1, and the ATG12-ATG5 conjugate. The morphological findings of hematoxylin and eosin staining in lung tissues and the pulmonary wet/dry weight ratio showed that lung injury improved in HSR + DEX rats. However, chloroquine (CQ), an autophagy inhibitor, abolished this effect. Detecting the concentration of autophagy-related proteins showed that DEX administration increased LC3, ATG12-ATG5, and Beclin-1 expression and decreased P62 expression. The expression levels of these proteins were similar to those in the HSR group after CQ + DEX administration. In summary, DEX induced autophagic activation in an HSR model. These findings suggest that DEX administration partially ameliorates HSR-induced lung injury via autophagic activation.

Trends and Outcomes of ST-Segment-Elevation Myocardial Infarction Among Young Women in the United States.

Background Although there has been a decrease in the incidence of ST-segment-elevation myocardial infarction (STEMI) in the United States, this trend might be stagnant or increasing in young women. We assessed the trends, characteristics, and outcomes of STEMI in women aged 18 to 55 years. Methods and Results We identified 177 602 women aged 18 to 55 with the primary diagnosis of STEMI from the National Inpatient Sample during years 2008 to 2019. We performed trend analyses to assess hospitalization rates, cardiovascular disease (CVD) risk factor profile, and in-hospital outcomes stratified by three age subgroups (18-34, 35-44, and 45-55 years). We found STEMI hospitalization rates were decreased in the overall study cohort from 52 per 100 000 hospitalizations in 2008 to 36 per 100 000 in 2019. This was driven by decreased proportion of hospitalizations in women aged 45 to 55 years (74.2% to-71.7%; P<0.001). Proportion of STEMI hospitalizationincreased in women aged 18-34 (4.7%-5.5%; P<0.001) and 35-44 years (21.2%-22.7%; P<0.001). The prevalence of traditional and non-traditional female-specific or female-predominant CVD risk factors increased in all age subgroups. The adjusted odds of in-hospital mortality in the overall study cohort and age subgroups were unchanged throughout the study period. Additionally, we observed an increase in the adjusted odds of cardiogenic shock, acute stroke, and acute kidney injury in the overall cohort over the study period. Conclusions STEMI hospitalizations are increasing among women aged <45 years, and in-hospital mortality has not changed over the past 12 years in women aged <55 years. Future studies on the optimization of risk assessment and management of STEMI in young women are urgently needed.

A case of preeclampsia with severe features following septic shock and drug-induced acute kidney injury

Abstract Objectives This article outlines a process for differentiating preeclampsia from other potential causes of end-organ damage in a critically ill patient. Case Presentation A patient in her early 30s, G2P1001 with intrauterine pregnancy at 12 weeks’ gestation was admitted seven months after delivering her first child due to new-onset psychosis and starvation ketosis. She was started on lithium for postpartum psychosis at 20 weeks’ gestation. She subsequently developed respiratory failure at 26 weeks’ gestation due to aspiration pneumonia in the setting of lithium toxicity, requiring admission to the intensive care unit (ICU) and intubation. She received antibiotics and vasopressors for suspected septic shock in addition to dialysis for lithium-induced acute kidney injury. One week after ICU admission, her sepsis resolved, her serum creatinine levels returned to normal, and her respiratory status improved. However, after vasopressors were discontinued, she suddenly developed persistently elevated blood pressures with proteinuria and elevated liver function tests (LFT’s). Due to concern for preeclampsia with severe features and rapidly increasing LFT’s, the patient underwent cesarean delivery at 27 weeks’ gestation. Conclusions In a critically ill patient with multiple comorbidities, it can be difficult to diagnose preeclampsia using the standard criteria. It is important to exclude other potential etiologies, as a misdiagnosis can have potentially devastating consequences.

Risk factors associated with prolonged intensive care unit stay in post coronary artery bypass grafting patients with chronic kidney disease.

Prolonged intensive care unit stay not only increases hospital cost but it also prevents hospital equipment to be used by other patients who need them. The aim of this study was to identify factors that affect the duration of intensive care unit stay in post coronary artery bypass grafting patients with chronic kidney disease. This is a single centered observational prospective study done on 191 post coronary artery bypass grafting patients from June 2018 to April 2019 at Cardiac Surgery Unit of Doctor's hospital and medical center, Lahore, Pakistan. Patients above 18 years with and without chronic kidney disease were included. Mean age of the patients was 57.83 years (± 9.862 SD. Logistic regression analysis shows that patients with post op arrhythmias had the strongest positive association with prolonged intensive care unit stay (OR:11; p value :<0.01), followed by recent myocardial infarction less than 90 days pre coronary artery bypass grafting (OR:5.93; p value:<0.01), shock (OR:3.93;p value:0.04) and acute kidney injury (OR :2.08;p value:0.04). 37.5% chronic kidney disease patients with recent myocardial infarction less than 90 days pre coronary artery bypass grafting and 51.4% patients of chronic kidney disease found with acute kidney injury, showed significant association with p values less than 0.05. Post op arrhythmias, recent myocardial infarction, shock and acute kidney injury are independent risk factors causing prolonged intensive care unit stay in post coronary artery bypass grafting patients.

Characteristics of patients resuscitated after burn related out-of-hospital cardiac arrest

AimThis study’s objective was to describe the characteristics of burn injury patients who were resuscitated after burn related out-of-hospital cardiac arrest (OHCA). MethodWe conducted a retrospective cohort study and examined characteristics of burn related OHCA using data from a Japanese nationwide burn registry that was collected between April 1, 2011 and March 31, 2020. First, we compared the characteristics of burn patients with and without OHCA. Second, among burn patients with OHCA, we compared the characteristics of survivors with non-survivors. ResultsIn the database, there were 16,995 hospitalised burn patients and 256 burn related OHCA. Thirty-two of the 256 burn patients (13%) survived after admission. Among patients with burns who also had OHCA, flames were the most common injury mechanism (74%); in comparison to all other injury mechanisms, the rate of flame burn was significantly higher in burn patients with OHCA than in burn patients without OHCA. The most common cause of death for burn related OHCA is carbon-monoxide poisoning (46%). Compared with survivors, non-survivors had a larger burn area, greater age and more complications. such as inhalation injuries and perineal burn injuries. Compared to other mechanisms of burn injury, electrical burn injuries were more common among survivors. In twelve patients with electrical burns, eight patients survived (67%) OHCA; of those eight patients, six (50%) could be discharged home. ConclusionPatients with burn related OHCA have a poor prognosis; however, patients who sustain electrical shock injuries may do better.

Inflammation, coagulation, and cellular injury in heat-induced shock.

The number of heatstroke victims hit record numbers in 2022 as global warming continues. In heat-induced injuries, circulatory shock is the most severe and deadly complication. This review aims to examine the mechanisms and potential approaches to heat-induced shock and the life-threatening complications of heatstroke. A computer-based online search was performed using the PubMed database and Web of Science database for published articles concerning heatstroke, shock, inflammation, coagulopathy, endothelial cell, cell death, and heat shock proteins. Dehydration and heat-induced cardiomyopathy were reported as the major causes of heat-induced shock, although other heat-induced injuries are also involved in the pathogenesis of circulatory shock. In addition to dehydration, the blood volume decreases considerably due to the increased vascular permeability as a consequence of endothelial damage. Systemic inflammation is induced by factors that include elevated cytokine and chemokine levels, dysregulated coagulation/fibrinolytic responses, and the release of damage-associated molecular patterns (DAMPs) from necrotic cell death that cause distributive shock. The cytoprotective heat shock proteins can also facilitate circulatory disturbance under excess heat stress. Multiple mechanisms are involved in the pathogenesis of heat-induced shock. In addition to dehydration, heat stress-induced cardiomyopathy due to the thermal damage of mitochondria, upregulated inflammation via damage-associated molecular patterns released from oncotic cells, unbalanced coagulation/fibrinolysis, and endothelial damage are the major factors that are related to circulatory shock.

Neonatal Dengue- A Case Series

Dengue is one of the commonest arboviral infections seen in children but in neonates, it is a disregarded entity. It can be acquired either through vertical (transplacental) or horizontal transmission (mosquito bite). It usually presents with fever, lethargy, poor feeding, and thrombocytopenia which can be accompanied by hepatosplenomegaly, transaminitis, fluid leak, petechiae, bleeding, Acute Respiratory Distress Syndrome (ARDS), shock and Acute Kidney Injury (AKI). Dengue shock in neonates responds well to dopamine if used early. A retrospective review of case records of five neonates admitted with dengue fever from October 2021 to October 2022 showed the neonates average age was 10 days and male:female ratio of 3:2. Three cases had horizontal and two cases had vertical transmission. All neonates presented with fever and were admitted within one week of illness. Petechial rashes and refusal of feeds were observed in two cases. Four cases had leukopenia whereas, all cases had thrombocytopenia. Sepsis was ruled out. Dengue Nonstructural protein 1 (NS1) antigen was positive in four cases. IgM antibody was positive in all while IgG was negative in all cases. None of the cases had hepatic derangement except for mild transaminitis in three cases. Only two cases had severe thrombocytopenia requiring platelet transfusion, but none developed bleeding, plasma leakage, shock requiring inotropes or fluid overload. Mortality due to neonatal dengue was nil and the duration of hospital stay ranged between 6-12 days. In the vertically transmitted cases, isolation of the virus from the breast milk or cord blood was not done due to logistics. Therefore, dengue fever can be suspected as one of the differentials in any neonate presenting with fever, leukopenia, and thrombocytopenia mimicking sepsis, especially during the epidemic season.

The significance of glycocalyx in surgery.

Surgical treatment is associated with an unwanted response of the organism to the so-called surgical trauma. This response is called surgical stress. Ischaemia-reperfusion injury is one of essential causes of tissue damage. It comprises functional and structural changes in tissue that occur after the restoration of circulation, after an episode of ischaemia. Necrosis of irreversibly changed cells and endothelial and mitochondrial-induced tissue swelling occur. Physiology, pathophysiology of endothelial glycocalyx: Endothelial glycocalyx is a 0.2 to 5 micrometres thin heteropolysaccharide layer that covers the endothelium on its intraluminal side. Backbone molecules of the glycocalyx include proteoglycans, glycoproteins, and glycosaminoglycans. Damage of the endothelial glycocalyx was described in trauma patients, in patients with septic shock, in ischemia and reperfusion injury, and during extensive surgical procedures. Approaches to prevent endothelial glycocalyx damage: Remote ischemic preconditioning was tested as a method of ischemia and reperfusion injury prevention during and after surgery. Nevertheless, the expected effect was not confirmed in performed meta-analyses. Endothelial glycocalyx damage can be prevented pharmacologically with a broad spectrum of substances, such as antithrombin III, doxycycline, hydrocortisone, etanercept, or nitric oxide donors. Hydrogen inhalation or albumin affects glycocalyx positively. Sulodexide provides a positive effect on the protection and reparation of endothelial glycocalyx. This proteoglycan with antithrombotic, fibrinolytic, hypofibrinogenemic, and lipolytic function is used for the treatment of venous diseases, ischaemic heart disease, and peripheral arterial disease. A positive effect of sulodexide on renal dysfunction was documented in a model of ischaemia and reperfusion injury. Equally, a positive effect of sulodexide was described on endothelium repair after its mechanical damage. Further research needs to be performed to evaluate the effect of endothelium-protectives on glycocalyx damage prevention and repair in ischaemia and reperfusion models involving large laboratory animals or in clinical trials in patients undergoing surgical revascularisation procedures.

Diurnal raptors at rescue centres in the Czech Republic: Reasons for admission, outcomes, and length of stay.

Rescue centres play an important role in the protection of raptors living in the wild by caring for injured or debilitated animals and abandoned young with the aim of returning them to the wild. A total of 22,538 raptors were admitted to 34 rescue centres in the Czech Republic in the years 2010-2019, with an increasing trend during the monitored period (rSp = 0.7333, p < 0.05). The most frequent reasons for their admission were other injuries and fractures (26.52%), the admission of young (22.98%), and the admission of raptors injured by electric shock injuries (20.51%). It proved possible to release 42.45% of admitted raptors back into the wild, the majority of which (91.05%) were released using the hard-release method. Foster parents were used in 1% of cases and a replacement nest in 0.2% of cases involving the rearing of young. In spite of all the care provided at rescue centres, a total of 39.97% of raptors admitted either died or had to be euthanized. Among them, most raptors were euthanized or died due to injuries caused by collision with a vehicle, electric shock injuries, and other injuries. This generally occurred shortly after admission (a median of two days). The importance of the work of rescue centres lies not merely in returning injured raptors back into the wild (which proves possible in around half of all cases), but also in obtaining information about the factors endangering raptors in the wild and contributing toward a decline in their populations. The findings provide information about human-wildlife interactions in the Czech Republic and their implications for conservation as well as on the effectiveness of rescue centres to successfully treat and subsequently release raptors back into the wild.

Parameters associated with successful weaning of veno-arterial extracorporeal membrane oxygenation: a systematic review

PurposeVeno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can be used to restore organ perfusion in patients with cardiogenic shock until native heart recovery occurs. It may be challenging, however, to determine when patients can be weaned successfully from ECMO—surviving without requiring further mechanical support or heart transplant. We aimed to systematically review the medical literature to determine the biomarkers, hemodynamic and echocardiographic parameters associated with successful weaning of VA-ECMO in adults with cardiogenic shock and to present an evidence-based weaning algorithm incorporating key findings.MethodWe systematically searched PubMed, Embase, ProQuest, Google Scholars, Web of Science and the Grey literature for pertinent original research reports. We excluded studies limited to extracorporeal cardiopulmonary resuscitation (ECPR) as the neurological prognosis may significantly alter the decision-making process surrounding the device removal in this patient population. Studies with a mixed population of VA-ECMO for cardiogenic shock or cardiac arrest were included. We excluded studies limited to patients in which ECMO was only used as a bridge to VAD or heart transplant, as such patients are, by definition, never “successfully weaned.” We used the Risk of Bias Assessment tool for Non-Randomized Studies. The study was registered on the International prospective register of systematic reviews (PROSPERO CRD42020178641).ResultsWe screened 14,578 records and included 47 that met our pre-specified criteria. Signs of lower initial severity of shock and myocardial injury, early recovery of systemic perfusion, left and right ventricular recovery, hemodynamic and echocardiographic stability during flow reduction trial and/or pump-controlled retrograde trial off predicted successful weaning. The most widely used parameter was the left ventricular outflow tract velocity time integral, an indicator of stroke volume. Most studies had a moderate or high risk of bias. Heterogeneity in methods, timing, and conditions of measurements precluded any meta-analysis.ConclusionsIn adult patients on VA-ECMO for cardiogenic shock, multiple biomarkers, hemodynamic and echocardiographic parameters may be used to track resolution of systemic hypoperfusion and myocardial recovery in order to identify patients that can be successfully weaned.Graphical

Analysis of monitoring effect on Hybrid Electric Field for AC/DC Cross Line

Electrostatic induction charge which generated by the coupling effect of hybrid electric field of AC/DC cross line and metal object under the transmission line can cause different levels of electric shock injury to human. In order to find out the distribution law of the hybrid electric field and reduce the effect of electrostatic induction, this paper set up shielding lines which paralleled to the AC and DC lines respectively on the outside of the side conductors and along the diagonal of parallelogram at crossing point, then measured the electric field distribution in shielding areas of 750kV AC and 500kV DC lines and the induced voltages of shielding lines in different states, analyzed the effect of shielding line on power frequency electric field and DC composite electric field. The results showed that shielding lines have a reducing effect on the hybrid electric field of the cross lines, the average power frequency field strength is reduced by 12.6%, the DC composite field and power frequency electric field at the crossing position was far less than the limits specified in the respective standards. Both induced voltage of bare lines and shielding lines wrapped with adhesive tape increase with the raise of erection height. Under the same conditions, the average induction voltage of bare conductor is 9.3% higher than that of shielding lines wrapped with adhesive tape. There is no obvious difference between parallel and vertical erection methods of the same number of shielding lines in the degree of reduction of induced voltage.

New potential for an old kid on the block: Impact of premorbid metformin use on lactate kinetics, kidney injury and mortality in sepsis and septic shock, an observational study.

Sepsis and septic shock cause significant mortality worldwide, with no targeted molecular therapies available. Metformin has pleomorphic effects that may be beneficial in sepsis, but at present, the impact of metformin exposure on sepsis remains controversial. Metformin might alter lactate metabolism, but little is known about its influence on lactate kinetics. We therefore investigated the impact of preadmission metformin use on lactate kinetics, acute kidney injury (AKI) and mortality in sepsis. We retrospectively analysed all ICU admissions with sepsis and septic shock between January 2013 and September 2020, identifying 77 users and 390 nonusers (subdivided in diabetics, n= 48 and nondiabetics, n= 342). (Sub)groups did not differ in illness severity or sepsis aetiology. Admission lactate levels were similar, but evolution in lactate over the first 24 h showed a larger decrease in users vs nonusers (median - 53% vs. -36%, p= .010). No difference in AKI or renal replacement therapy was found. Mortality was lower in users vs nonusers in case of septic shock (21.9% (n= 7) vs. 42.7% (n= 61) for 90d mortality, p= .029, OR 0.38 [95% CI: 0.15-0.93]), but showed no significant differences in the combined sepsis and septic shock population. In our data, preadmission metformin use is associated with a significantly larger decrease in lactate after admission with sepsis or septic shock and with reduced mortality in septic shock. This underscores the need for further studies investigating the interplay between metformin, lactate and sepsis, thereby exploring the potential use of metformin or its pathways in sepsis.

Clinical characteristics of COVID-19 patients who underwent tracheostomy and its effect on outcome: A retrospective observational study.

The exponential rise in Coronavirus disease 2019 (COVID-19) cases has resulted in an increased number of patients requiring prolonged ventilatory support and subsequent tracheostomy. With the limited availability of literature regarding the outcomes of COVID-19 patients with tracheostomy, we attempted to study the clinical characteristics and multiple parameters affecting the outcomes in these patients. To determine all-cause mortality following tracheostomy and its association with various risk factors in COVID-19 patients. This retrospective study included 73 adult COVID-19 patients admitted to the ICU between 1 April, 2020 and 30 September, 2021 who underwent tracheostomy as a result of acute respiratory failure due to COVID-19. The data collected included demographics (age, sex), comorbidities, type of oxygen support at admission, severity of COVID-19, complications, and other parameters such as admission to tracheostomy, intubation to tracheostomy, ICU stay, hospital stay, and outcome. This study included 73 adult patients with an average age of 52 ± 16.67 years, of which 52% were men. The average time for admission to tracheostomy was 18.12 ± 12.98 days while intubation to tracheostomy was 11.97 ± 9 days. The mortality rate was 71.2% and 28.8% of patients were discharged alive. The mean duration of ICU and hospital stay was 25 ± 11 days and 28.21 ± 11.60 days, respectively. Greater age, severe COVID-19, mechanical ventilation, shock and acute kidney injury were associated with poor prognosis; however, early tracheostomy in intubated patients resulted in better outcomes. Patients with severe COVID-19 requiring mechanical ventilation have a poor prognosis but patients with early tracheostomy may benefit with no added risk. We recommend that the timing of tracheostomy be decided on a case-by-case basis and a well-designed randomised controlled trial should be performed to elucidate the potential benefit of early tracheostomy in such patients.

Abstract 14745: Recurrent Cardiogenic Shock Secondary to Shoshin Beriberi in s Patient With Heavy Alcohol Use

Introduction: Thiamine is an essential enzyme cofactor in cellular metabolism. Its deficiency can manifest as wet beriberi with high-output heart failure. Its more severe and fulminant form is known as shoshin beriberi, characterized by cardiogenic shock, hemodynamic collapse, and multiorgan failure. Case Description: A 67-year-old male presented with dyspnea on exertion and orthopnea. On exam, he was tachycardic and cold to the touch. Initial workup showed metabolic acidosis, elevated lactate, acute kidney and liver injury, and elevated NT proBNP. ECG showed atrial fibrillation with RVR. His past medical history included heavy alcohol use and a similar presentation two years prior with new-onset heart failure complicated by shock and acute kidney injury, requiring CRRT. At that time, he improved with high-dose thiamine and decompensation was attributed to shoshin beriberi. Shortly after admission, the patient developed worsening shock, with liver failure, renal failure, and DIC. He was started on pressors, broad-spectrum antibiotics, high-dose thiamine and CRRT. TTE showed biventricular dysfunction and global hypokinesis with LVEF of 20%. Hemodynamic monitoring was consistent with cardiogenic shock. Infectious workup was negative. Within 96h of the initiation of thiamine, the patient’s mental status and hemodynamics significantly improved, with resolution of cardiogenic shock. He remained hemodynamically stable, his laboratory abnormalities improved, and he was started on GDMT. He required intermittent HD for several months, after which it was discontinued. He later underwent LHC that showed nonobstructive CAD. Discussion: The diagnosis of shoshin beriberi is challenging and requires a high index of suspicion for presumed thiamine deficiency, particularly in critically ill patients with many comorbidities. An empiric therapeutic trial of thiamine supplementation in this group of patients can lead to improvement of hemodynamics within hours to days, as in this case. Even though his LVEF has not yet fully recovered, we suspect that his presentation was due to an acute-on-chronic insult, in the setting of alcohol-induced cardiomyopathy. To the best of our knowledge, this is the first report of recurrent shoshin beriberi in the literature.

PCI for acute myocardial infarction in patients with a pre-existing LVAD, does it improve survival?

It is well established that percutaneous coronary intervention (PCI) is a life-saving procedure for acute myocardial infarction (AMI) in the general population and is guideline-recommended for both STEMI and NSTEMI. There is little literature regarding its use in patients with a pre-implanted Left Ventricular Assist Device (LVAD). We retrospectively analyzed data from the National Inpatient Sample (NIS) Database to select all US adult patients (>18 years) with an LVAD diagnosed with an AMI divided into two groups; those who received PCI during the hospitalization and those who did not. A total of 3722 LVAD patients with AMI were identified, of these 17% of patients received PCI and 83% did not. After propensity matching of LVAD patients with AMI, there were 626 patients who received PCI and 623 who did not. Of patients receiving PCI, 37.5% had a STEMI while 29.7% of patients who did not receive PCI had STEMI. Rates of kidney injury (36.5% vs. 43.3%, OR 0.75, 95% CI 0.60-0.94, p=0.016), sepsis (3.2% vs. 11.4%, OR 0.26, 95% CI 0.15-0.43, p < 0.001), cardiogenic shock (44.1% vs. 50.4%, OR 0.78, 95% CI 0.62-0.97, p=0.03) and mortality (17.4% vs. 28.9%, OR 0.52, 95% CI 0.40-0.68, p < 0.001) were all better for patients receiving PCI. Vascular complications (1.4% vs. 0%, p=0.008) and intracerebral hemorrhage (ICH) (1.6% vs. 0, p=0.004) were both more common in the group receiving PCI. In this study, patients supported by LVAD with AMI had an elevated risk of mortality compared to generally accepted mortality rates of patients without LVAD. In this analysis PCI was associated with a decreased risk of mortality, cardiogenic shock, and kidney injury while increasing the risk for vascular complications and intracranial hemorrhage.

Hemorrhagic shock and tissue injury provoke distinct components of trauma-induced coagulopathy in a swine model.

Tissue injury (TI) and hemorrhagic shock (HS) are the major contributors to trauma-induced coagulopathy (TIC). However, the individual contributions of these insults are difficult to discern clinically because they typically coexist. TI has been reported to release procoagulants, while HS has been associated with bleeding. We developed a large animal model to isolate TI and HS and characterize their individual mechanistic pathways. We hypothesized that while TI and HS are both drivers of TIC, they provoke different pathways; specifically, TI reduces time to clotting, whereas, HS decreases clot strength stimulates hyperfibrinolysis. After induction of general anesthesia, 50kg male, Yorkshire swine underwent isolated TI (bilateral muscle cutdown of quadriceps, bilateral femur fractures) or isolated HS (controlled bleeding to a base excess target of -5mmol/l) and observed for 240min. Thrombelastography (TEG), calcium levels, thrombin activatable fibrinolysis inhibitor (TAFI), protein C, plasminogen activator inhibitor 1 (PAI-1), and plasminogen activator inhibitor 1/tissue-type plasminogen activator complex (PAI-1-tPA) were analyzed at pre-selected timepoints. Linear mixed models for repeated measures were used to compare results throughout the model. TI resulted in elevated histone release which peaked at 120min (p = 0.02), and this was associated with reduced time to clot formation (R time) by 240min (p = 0.006). HS decreased clot strength at time 30min (p = 0.003), with a significant decline in calcium (p = 0.001). At study completion, HS animals had elevated PAI-1 (p = 0.01) and PAI-1-tPA (p = 0.04), showing a trend toward hyperfibrinolysis, while TI animals had suppressed fibrinolysis. Protein C, TAFI and skeletal myosin were not different among the groups. Isolated injury in animal models can help elucidate the mechanistic pathways leading to TIC. Our results suggest that isolated TI leads to early histone release and a hypercoagulable state, with suppressed fibrinolysis. In contrast, HS promotes poor clot strength and hyperfibrinolysis resulting in hypocoagulability.

Application of Different Continuous Renal Replacement Therapy Hemofilter in Patients with Septic Shock Complicated with Acute Renal Injury.

We aimed to compare the clinical effects of continuous renal replacement therapy (CRRT) with different hemofilters in patients with septic shock and acute kidney injury (AKI). Thirty patients with septic shock complicated with AKI admitted to The Fourth Affiliated Hospital of Anhui Medical University from 2018-2020 were selected and divided into the control and observation groups. The control group was treated with CRRT using the conventional ST-100 hemofilter. The observation group was treated with CRRT using the oXiris hemofilter for 48 hours, followed by CRRT with the conventional ST-100 hemofilter. Infection indexes, sepsis-related organ failure assessment (SOFA), changes in corresponding organ function indexes, duration of each treatment, and death were compared between the two groups during CRRT. The white blood cells (WBC) count, high-sensitivity C-reactive protein (hs-CRP), and procalcitonin (PCT) levels were significantly decreased in the oXiris group 48 hours after CRRT (P= 0.048, 0.036, 0.031, respectively). After 48 hours of CRRT, SOFA score, serum lactic acid, and norepinephrine dose in the oXiris group were significantly lower than those in the control group (P= 0.039, 0.002, 0.021, respectively). The use time of vasoactive drugs and the treatment time of CRRT in the oXiris group was significantly shortened (P= 0.031 and 0.029, respectively). However, there were no significant differences in mechanical ventilation duration, intensive care unit (ICU) hospitalization time, total hospitalization time, ICU mortality, and in-hospital mortality. For patients with septic shock complicated by AKI, CRRT treatment with the oXiris hemofilter could effectively clear inflammatory cytokine levels and quickly correct hemodynamic disorders, thus accelerating the recovery of organ function.

Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden

BackgroundHistorically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy.MethodsRetrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors.ResultsAmong the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min.ConclusionSurvival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines.

IMPACT OF THE KOMAPE JUDGMENT ON THE SOUTH AFRICAN COMMON LAW OF DELICT: AN ANALYTICAL REVIEW Komape v Minister of Basic Education [2020] 1 All SA 651 (SCA); 2020 (2) SA 347 (SCA)

In a rare case where the State is mulcted with delictual damages for failure to discharge their constitutional obligations to provide infrastructure in public schools, such as adequate sanitation facilities, the Supreme Court of Appeal awarded damages for emotional shock to the parents and siblings of a Grade-R learner who had drown in a pit-toilet. At the same time, the Court refused to develop the Constitution, 1996, to award separate damages for pure grief and bereavement not accompanied by serious psychological lesions, as well as constitutional damages. The judgment has been widely welcomed by children rights activities and is regarded as heralding a new era in holding the State (education officials) accountable for failure to fulfill their constitutional obligations towards learners, especially regarding the eradication of pit latrines in public schools.&#x0D; This note gives an analytical review of the judgment and is impact on the (development of) the common law delict, in particular, in the area of emotional shock and psychological injury. In the process, the case note specifically takes interest in the rationality for the SCA's rejection of the Appellants' argument for the development of the common law to award damages for a pure grief and bereavement (in addition to damages for emotional shock and psychological lesions) and constitutional damages. In the end, the case note concurs with the Court that it was unnecessary in the circumstances of the case to develop the common law. In fact, it is asserted in this note that the common law delict of emotional shock, in its current form, adequately compensate victims. Therefore, the SCA was right to reject the argument to develop the common law, as well as the awarding of constitutional damages.