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Plurad, David, Howard Belzberg, Ira Schulman, Donald Green, Ali Salim, Kenji Inaba, Peter Rhee, and Demetrios Demetriades. "Leukoreduction is Associated with a Decreased Incidence of Late Onset Acute Respiratory Distress Syndrome after Injury." American Surgeon 74, no. 2 (February 2008): 117–23. http://dx.doi.org/10.1177/000313480807400205.
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Transfusions are known to be associated with Acute Respiratory Distress Syndrome (ARDS). Transfusion of leukoreduced products may be associated with a decreased incidence of late posttraumatic ARDS (late ARDS). Data from ventilated and transfused trauma patients were analyzed. Key variables in the first 48 hours of admission were studied for their associations with late ARDS and examined for changes over the 6 year study period. Late ARDS developed in 244 of the 1488 patients studied (16.4%). The incidence in patients given nonleukoreduced (NLR) product was 30.4 per cent (75/247) versus 13.6 per cent (169/1241) for patients not exposed [2.77 (2.02–3.73), P < 0.001]. Exposure to NLR products (50.9% in 2000 vs 1.9% in 2005) and incidence of ARDS (26.3% in 2000 vs 6.3% in 2005) significantly decreased. Treatment variables independently associated with late ARDS were NLR product exposure, Total Parenteral Nutrition exposure, Peak Inspiratory Pressure ≥ 30 mm Hg, fluid balance ≥ 2 liters at 48 hours, and transfusion of ≥ 10 units of any product. NLR product exposure has an association with an increased incidence of late onset posttraumatic ARDS which is independent of large volume transfusions. Leukoreduction should be routinely included in an overall treatment strategy to furthermore mitigate this complication in critically ill trauma patients.
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Chaiwat, Onuma, John D. Lang, Monica S. Vavilala, Jin Wang, Ellen J. MacKenzie, Gregory J. Jurkovich, and Frederick P. Rivara. "Early Packed Red Blood Cell Transfusion and Acute Respiratory Distress Syndrome after Trauma." Anesthesiology 110, no. 2 (February 1, 2009): 351–60. http://dx.doi.org/10.1097/aln.0b013e3181948a97.
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Background Transfusion of packed red blood cells (PRBCs) is a risk factor for acute respiratory distress syndrome (ARDS) in trauma patients. Yet, there is a paucity of information regarding the risk of ARDS with incremental PRBCs exposure. Methods For this retrospective analysis, eligible patients from National Study on Costs and Outcomes of Trauma were included. Our main exposure was defined as units of PRBCs transfused during the first 24 h after admission. The main outcome was ARDS. Results A total of 521 (4.6%) of 14070 patients developed ARDS, and 331 patients (63.5%) who developed ARDS received PRBCs transfusion. Injury severity, thoracic injury, polytrauma, and pneumonia receiving more than 5 units of fresh frozen plasma and 6-10 units of PRBCs were independent predictors of ARDS. Patients receiving more than 5 units of PRBCs had higher risk of developing ARDS (patients who received 6-10 units: adjusted odds ratio 2.5, 95% CI 1.12-5.3; patients who received more than 10 units: odds ratio 2.6, 95% CI 1.1-6.4). Each additional unit of PRBCs transfused conferred a 6% higher risk of ARDS (adjusted odds ratio 1.06; 95% CI 1.03-1.10). Conclusions Early transfusion of PRBCs is an independent predictor of ARDS in adult trauma patients. Conservative transfusion strategies that decrease PRBC exposure by even 1 unit may be warranted to reduce the risk of ARDS in injured patients.
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Martucci, Gennaro, Giovanna Panarello, Giovanna Occhipinti, Veronica Ferrazza, Fabio Tuzzolino, Diego Bellavia, Filippo Sanfilippo, et al. "Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality." Journal of Intensive Care Medicine 34, no. 8 (May 2017): 630–39. http://dx.doi.org/10.1177/0885066617706339.
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Purpose: We describe an approach for anticoagulation and transfusions in veno-venous–extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24% to 30%. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7%) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P < .05). Sixty-two (75.6%) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P < .05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95% confidence interval [CI]: 1.1-3.2, P = .01); for the development of septic shock it was 15.4 (95% CI: 1.7-136.8, P = .01), and for each day of pre-ECMO stay it was 1.1 (95% CI: 1-1.2, P = .04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.
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Daher, Pamela, Pedro G. Teixeira, Thomas B. Coopwood, Lawrence H. Brown, Sadia Ali, Jayson D. Aydelotte, Brent J. Ford, Adam S. Hensely, and Carlos V. Brown. "Mild to Moderate to Severe: What Drives the Severity of ARDS in Trauma Patients?" American Surgeon 84, no. 6 (June 2018): 808–12. http://dx.doi.org/10.1177/000313481808400623.
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Acute respiratory distress syndrome (ARDS) is a complex inflammatory process with multifactorial etiologies. Risk factors for its development have been extensively studied, but factors associated with worsening severity of disease, as defined by the Berlin criteria, are poorly understood. A retrospective chart and trauma registry review identified trauma patients in our surgical intensive care unit who developed ARDS, defined according to the Berlin definition, between 2010 and 2015. The primary outcome was development of mild, moderate, or severe ARDS. A logistic regression model identified risk factors associated with developing ARDS and with worsening severity of disease. Of 2704 total patients, 432 (16%) developed ARDS. Of those, 100 (23%) were categorized as mild, 176 (41%) as moderate, and 156 (36%) as severe. Two thousand two hundred and seventy-two patients who did not develop ARDS served as controls. Male gender, blunt trauma, severe head and chest injuries, and red blood cell as well as total blood product transfusions are independent risk factors associated with ARDS. Worsening severity of disease is associated with severe chest trauma and volume of plasma transfusion. Novel findings in our study include the association between plasma transfusions and specifically severe chest trauma with worsening severity of ARDS in trauma patients.
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Malouf, M., and A. R. Glanville. "Blood Transfusion Related Adult Respiratory Distress Syndrome." Anaesthesia and Intensive Care 21, no. 1 (February 1993): 44–49. http://dx.doi.org/10.1177/0310057x9302100112.
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Adult respiratory distress syndrome (ARDS) is a rare but important complication of blood transfusion because it has a mortality rate of 50–60%. ARDS is characterised by noncardiogenic pulmonary oedema and is often associated with major trauma and/or sepsis. Clinical features include dyspnoea, tachypnoea, chills and extensive crepitations. The pathogenesis has not been elucidated completely and a number of hypotheses have been proposed. Factors which have been implicated include neutrophil sequestration and complement activation, macrophages, metabolites of the arachidonic acid cascade and cytokines, all of which contribute to the amplification of the inflammatory process. In particular, leucoagglutinins have been implicated with blood transfusions. Treatment is generally supportive as specific therapeutic strategies remain largely unproven.
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Rajasekaran, Surender, Dominic Sanfilippo, Allen Shoemaker, Scott Curtis, Sandra Zuiderveen, Akunne Ndika, Michael Stoiko, and Nabil Hassan. "Respiratory Impairment after Early Red Cell Transfusion in Pediatric Patients with ALI/ARDS." Critical Care Research and Practice 2012 (2012): 1–6. http://dx.doi.org/10.1155/2012/646473.
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Introduction. In the first 48 hours of ventilating patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), a multipronged approach including packed red blood cell (PRBC) transfusion is undertaken to maintain oxygen delivery.Hypothesis. We hypothesized children with ALI/ARDS transfused within 48 hours of initiating mechanical ventilation would have worse outcome. The course of 34 transfused patients was retrospectively compared to 45 nontransfused control patients admitted to the PICU at Helen DeVos Children’s Hospital between January 1st 2008 and December 31st 2009.Results. Mean hemoglobin (Hb) prior to transfusion was 8.2 g/dl compared to 10.1 g/dl in control. P/F ratio decreased from135.4±7.5to116.5±8.8in transfused but increased from148.0±8.0to190.4±17.8(P<0.001) in control. OI increased in the transfused from11.7±0.9to18.7±1.6but not in control. Ventilator days in the transfused were15.6±1.7versus9.5±0.6days in control (P<0.001). There was a trend towards higher rates of MODS in transfused patients; 29.4% versus 17.7%, odds ratio 1.92, 95% CI; 0.6–5.6 Fisher exactP<0.282.Conclusion. This study suggests that early transfusions of patients with ALI/ARDS were associated with increased ventilatory needs.
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Seong, Gil Myeong, Yunkyoung Lee, Sang-Bum Hong, Chae-Man Lim, Younsuck Koh, and Jin Won Huh. "Prognosis of Acute Respiratory Distress Syndrome in Patients With Hematological Malignancies." Journal of Intensive Care Medicine 35, no. 4 (January 17, 2018): 364–70. http://dx.doi.org/10.1177/0885066617753566.
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Introduction: The intensive care unit (ICU) admission of patients with hematologic malignancies is gradually increasing. Life-threatening events are common, and acute respiratory distress syndrome (ARDS) is one of the most critical conditions. The aim of this study was to investigate the clinical characteristics and outcomes of ARDS in patients with hematological malignancies admitted to the ICU. Methods: A retrospective study was performed on all patients with ARDS with hematological malignancies in a single tertiary teaching hospital between 2008 and 2015. Data on the treatment of and the outcomes of ARDS were collected to determine the clinical characteristics associated with ICU mortality. Results: During the 8-year study period, among a total of 821 patients with ARDS admitted to the ICU, all 185 patients with hematological malignancies were included in the analysis. Most of the patients (88.1%) had moderate-to-severe ARDS, and the median PaO2/FiO2 ratio was 122 (interquartile range: 88-157). The overall ICU mortality rate was 57.3% (50.0% for mild, 52.0% for moderate, and 67.7% for severe ARDS). After the univariate and the multivariate logistic regressions, the factors independently associated with a higher ICU mortality were severe ARDS (odds ratio [OR]: 2.47; 95% confidence interval [CI]: 1.17-5.25), identification of carbapenem-resistant gram-negative bacteria (OR: 6.61; 95% CI: 1.31-33.41), the amount of blood product transfusion (OR: 1.25; 95% CI: 1.13-1.38), and the progressive or refractory disease (OR: 3.01; 95% CI: 1.31-6.91). Mortality was independently lower in patients who received the initial low tidal volume ventilation (OR: 0.37, 95% CI: 0.14-0.96). Conclusion: The outcome of ARDS in patients with hematological malignancies is associated with the severity of the underlying diseases, the presence of multidrug-resistance pathogens, and the amount of transfusion; however, strict application of low tidal volume ventilation may improve the outcome of these patients at the time of diagnosis.
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Panholzer, Bernd, Katrin Meckelburg, Katharina Huenges, Grischa Hoffmann, Michael von der Brelie, Nils Haake, Kevin Pilarczyk, Jochen Cremer, and Assad Haneya. "Extracorporeal membrane oxygenation for acute respiratory distress syndrome in adults: an analysis of differences between survivors and non-survivors." Perfusion 32, no. 6 (March 10, 2017): 495–500. http://dx.doi.org/10.1177/0267659117693075.
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Objectives: Over the last decade, extracorporeal membrane oxygenation (ECMO) has become a promising option for patients with severe acute respiratory distress syndrome (ARDS). In this single-center observational cohort study, data from a patient group with severe ARDS treated with ECMO was analyzed. Methods: Data from 46 patients [median age 54 years (18 to 72), male: 65.2%] were evaluated retrospectively between January 2009 and September 2015. Results: Diagnosis leading to ARDS was pneumonia in 63.1% of the patients. The median SOFA Score was 13 (10 to 19) and the median LIS was 3.5 (2.67 to 4). The median duration of ECMO support was 12 days (1 to 86). Twenty-eight patients (60.9%) were successfully weaned from ECMO and 22 patients survived (47.8%). Non-survivors needed significantly more frequent renal replacement therapy (37.5% vs. 18.2%; p<0.01) and transfusion of red blood cell concentrates [0.4 units (0.3 to 1.2) vs. 0.9 units (0.5 to 1.6); p<0.01] during ECMO support compared to patients who survived. Conclusion: This report suggests that ECMO currently allows treatment of severe ARDS with presumed improved survival. The incidence rate of acute kidney injury and transfusion are associated with adverse outcomes.
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Masirevic, Vesna, Radoje Colovic, Marica Basic, Vitomir Rankovic, I. Palibrk, and Ljiljana Ivic. "TRALI syndrome: Noncardial lung oedema after blood transfusion." Acta chirurgica Iugoslavica 49, no. 1 (2002): 69–71. http://dx.doi.org/10.2298/aci0201069m.
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Definition - signs and symptoms which include dispnea, hypertension, high temperature and high productive tracheobronchial secretion. Physical findings are lung oedema in first four hours. Such patients usually require respiratory help. After adequate therapy, symptoms disappeared in 96 hours. In the beginning, TRALI used to be a part of ARDS and it were treated that way. Today, TRALI is understand like substantive group of symptoms.
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Lyons, William S. "Transfusion-Related Acute Lung Injury, Acute Lung Injury, and ARDS." Chest 128, no. 1 (July 2005): 470–71. http://dx.doi.org/10.1378/chest.128.1.470.
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Bakhtiar, Arief, and Rena Arusita Maranatha. "Acute Respiratory Distress Syndrome." Jurnal Respirasi 4, no. 2 (May 30, 2018): 51. http://dx.doi.org/10.20473/jr.v4-i.2.2018.51-60.
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Acute respiratory distress syndrome (ARDS) is a syndrome, a combination of clinical and physiological observations that describe a pathological state. The pathogenesis of ARDS is not completely clear and there is no gold standard for diagnosis. ARDS is characterized by non-cardiogenic pulmonary edema, inflammation of the lungs, hypoxemia, and decreased lung compliance. Acute is defined as a symptom that occurs within one week of a known risk factor. Early clinical manifestations are shortness of breath (dyspneu and tachypneu) which then quickly develop into respiratory failure. ARDS was first described in 1967 by Asbaugh, et al., then the AECC made a definition that was finally refined by Berlin's criteria. Berlin's criteria divided the degree of hypoxemia into 3, namely mild, moderate, and severe, based on the arterial PO2 / FiO2 ratio and the need for PEEP (5 cm H2O or more) which can be given via endotracheal tube or non-invasive ventilation. Sepsis, aspiration of fluid or gastric contents, and multipe transfusion (>15 units/24 hours) are associated with a high risk of ARDS. Cases of ARDS related to pulmonary sepsis, such as pneumonia, inhalational trauma, and pulmonary contusions are as much as 46% or non-pulmonary sepsis as much as 33%. ARDS management includes oxygen therapy and supportive therapy, such as hemodynamics, pharmacotherapy, and nutrition. Further studies are still needed to get a good outcome for ARDS patients.
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Wang, Kevin Y., Pratik Shah, and Matthew Pierce. "Convalescent plasma for COVID-19 complicated by ARDS due to TRALI." BMJ Case Reports 14, no. 1 (January 2021): e239762. http://dx.doi.org/10.1136/bcr-2020-239762.
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Convalescent plasma, which contains antibodies from recovered individuals, has been used as an effective treatment for infectious diseases in the past and is currently being used as a potential treatment option for COVID-19. Multiple studies have reported this treatment to be safe. We report a case of a patient who developed acute respiratory distress syndrome (ARDS) with features suggestive of transfusion-related acute lung injury after being treated with convalescent plasma for COVID-19. We emphasise the need to be aware of the potential risk of transfusion reactions and disease worsening with convalescent plasma administration and to weigh the risk and benefits of this therapy before administration to patients and propose that further study be done regarding the potential risks of convalescent plasma.
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Eichacker, Peter Q., James H. Shelhamer, Matthew Brenner, and Joseph E. Parrillo. "The Effects of Heterologous Platelet Transfusion on Pulmonary Function during ARDS." Chest 97, no. 4 (April 1990): 923–26. http://dx.doi.org/10.1378/chest.97.4.923.
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Crowley, James P. "The Effects of Heterologous Platelet Transfusion on Pulmonary Function during ARDS." Chest 99, no. 5 (May 1991): 1317. http://dx.doi.org/10.1378/chest.99.5.1317a.
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Odeyemi, Yewande, Svetlana Herasevich, Michelle Gong, and Ognjen Gajic. "Clinical Strategies to Prevent Acute Respiratory Distress Syndrome." Seminars in Respiratory and Critical Care Medicine 40, no. 01 (February 2019): 129–36. http://dx.doi.org/10.1055/s-0039-1683997.
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AbstractAcute respiratory distress syndrome (ARDS) remains an important clinical entity in the intensive care unit with a significant impact on morbidity and mortality. Effective therapeutic interventions are limited; thus current research focus has shifted from treatment to the prevention of this pulmonary syndrome. In recent decades, a decrease in the incidence of ARDS has been observed and this reduction is largely due to preventive strategies including safe lung ventilation practices, avoidance of iatrogenic exposures, and improvement in care of predisposing conditions such as sepsis and pneumonia. Early identification of at-risk patients, prompt treatment of predisposing conditions, and adoption of evidence-based best practice including restrictive transfusion strategies, conservative fluid management, avoidance of large tidal volume ventilation, and aspiration precaution practices are key preventive strategies with demonstrated benefits. There are currently no effective pharmacological preventive strategies for ARDS.
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Solh, Melhem, Shanna Morgan, Jeffrey Mc Cullough, Ryan Shanley, and Daniel J. Weisdorf. "Do Blood Transfusions Cause Pulmonary Complications Following Hematopoietic CELL Transplantation?" Blood 124, no. 21 (December 6, 2014): 2477. http://dx.doi.org/10.1182/blood.v124.21.2477.2477.
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Abstract Introduction Transfusion of blood products is an essential component of the hematopoietic cell transplantation (HCT) process. Blood transfusions mainly platelets and plasma, carry several risks including, but not limited to, acute and delayed lung injury, especially in critically ill patients. The effect of transfusions on lung complications post HCT has not been previously investigated. We studied 215 adult allogeneic HCT recipients at the University of Minnesota and examined the association between transfusion of blood components and development of lung complications post HCT. Methods 215 consecutive adult allogeneic HCT recipients were retrospectively analyzed for blood product utilization. Patients without lung complications were used as a control group and those with any lung complication prior to day 180 post HCT were the study cohort. Blood utilization was quantitated as the total number of transfusion episodes and the number of transfusion episodes per week divided into three time intervals: day 0-30, day 31-60, and day 61-180 after HCT. Transfusions were analyzed as density (episodes or units per week). Lung complication data was collected from the transplant database and merged with the transfusion data. The effects of transfusion density and other factors on the odds of ever having a lung complication were modeled using multivariable logistic regression. Results 195 patients were included in the analysis and 20 were excluded, mostly due to incomplete data. 113 (58%) of the patients developed lung events prior to day 180 post HCT. Of the 113 patients with lung events, 81 (72%) were related to infectious causes. The study group with pulmonary complications and controls had similar baseline demographic characteristics (age, gender, CMV serostatus, disease and disease risk and donor source). Six months survival was significantly lower in the lung complications group (52%) versus the controls (78%) p=0.01. Patients who developed lung events received more transfusions including: episodes per week during the first month following HCT (median 4.3 (range x-y) vs. 2.7 (x-y) for controls); platelet units per week (3.5 (range x-y) vs. 2.0 (x-y)); and RBC units per week (1.8 (x-y) vs. 1.4 (x-y)); p <0.01 for all. Transfusion episodes increased significantly in the week following each lung event compared to the preceding week (7.1 (range x-y) versus 5.5 (x-y); p=0.04). In multivariate analysis, the presence of any lung complication, use of an umbilical cord graft and occurrence of chronic GVHD were each independently associated with increased number of transfusion episodes post HCT. Table 1 shows factors that were significantly associated with increased blood utilization up to day 180. Conclusion These data suggest that transfusion of more blood products is associated with lung complications and their use increases after the lung events. Limiting use of blood components in the post HCT period is recommended, potentially to reduce the risks of lung events. Table 1: Risk factors for Transfusion episodes/week from day 1-180 post HCT All Transfusion Episodes RBC Units Platelet Units Risk factor Relative transfusion density P-value Relative density P-value Relative density P-value Control group 1.0 1.0 1.0 ARDS/IPS 4.1 <.01 3.7 <.01 3.5 <.01 DAH 4.3 <.01 4.7 <.01 5.7 <.01 Bacterial pneumonia 2.6 <.01 2.7 <.01 3.1 <.01 Pulmonary edema 2.6 <.01 3.4 <.01 2.9 <.01 Female 1.0 1.0 1.0 Male 0.9 0.36 1.0 0.83 1.0 0.86 Reduced intensity conditioning 1.0 1.0 1.0 Myeloablative with TBI 1.4 0.02 1.2 0.20 1.7 <.01 Myeloablative without TBI 1.8 0.05 1.6 0.14 1.3 0.66 CMV serostatus Recipient+ 1.0 1.0 1.0 CMV R-/Donor- 0.7 0.03 0.9 0.48 0.6 0.05 CMV R-/D+ 1.2 0.39 1.0 0.91 1.2 0.55 Sibling donor 1.0 1.0 1.0 Unrelated Adult donor 0.9 0.70 0.8 0.60 0.6 0.40 Unrelated umbilical cord blood donor 1.7 <.01 1.8 <.01 2.0 <.01 Standard risk disease 1.0 1.0 1.0 High risk disease 1.2 0.19 1.3 0.04 1.2 0.47 Abbreviations ARDS/IPS: Adult respiratory distress syndrome/Idiopathic pneumonia syndrome; DAH: Diffuse alveolar hemorrhage; NOS: not otherwise specified; TBI: total body irradiation; CMV: cytomegalovirus. Disclosures No relevant conflicts of interest to declare.
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Graw, Jan, David Baron, and Roland Francis. "Die Bedeutung der Hämolyse in Anästhesie und Intensivmedizin." AINS - Anästhesiologie · Intensivmedizin · Notfallmedizin · Schmerztherapie 53, no. 04 (April 2018): 296–305. http://dx.doi.org/10.1055/s-0043-121622.
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ZusammenfassungDie intravasale Hämolyse mit erhöhten Plasmakonzentrationen von zellfreiem Hämoglobin tritt nicht nur bei hämolytischen Erkrankungen auf – sie ist auch bei der Transfusion von Blutkonserven sowie bei Patienten mit ARDS, Sepsis oder kardiopulmonalem Bypass für den Krankheitsverlauf von Bedeutung. Dieser Beitrag möchte den klinisch tätigen Anästhesisten für die Relevanz der Hämolyse sowie deren Prävention und Früherkennung sensibilisieren.
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Fudala, Rafal, Agnieszka Krupa, Dorota Stankowska, Timothy C. Allen, and Anna K. Kurdowska. "Does activation of the FcγRIIa play a role in the pathogenesis of the acute lung injury/acute respiratory distress syndrome?" Clinical Science 118, no. 8 (January 26, 2010): 519–26. http://dx.doi.org/10.1042/cs20090422.
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ALI (acute lung injury) and its more severe form ARDS (acute respiratory distress syndrome) are inflammatory diseases of the lung characterized by hypoxaemia and diffuse bilateral infiltrates. Disruption of epithelial integrity and injury to endothelium are contributing factors of the development of ALI/ARDS, and alveolar damage is the most pronounced feature of ALI/ARDS. The resulting increase in lung microvascular permeability promotes influx of inflammatory cells to the alveolar spaces. Oedema fluid contains pro-nflammatory mediators and plasma proteins, including Igs (immunoglobulins). Moreover, several reports describe the presence of autoantibodies and immune complexes [anti-IL-8 (interleukin-8) autoantibody/IL-8 complexes] in lung fluids (oedema and bronchoalveolar lavage fluids) from patients with ALI/ARDS. These immune complexes associate with FcγRIIa (Fcγ IIa receptor) in lungs of patients with ARDS. Furthermore, the expression of FcγRIIa is substantially elevated in lungs of these patients. FcγRIIa appears on virtually all myeloid cells, platelets and endothelial cells. It is a low-affinity receptor for IgG that preferentially binds aggregated immunoglobulins and immune complexes. FcγRs regulate phagocytosis and cell-mediated cytotoxicity, and initiate the release of inflammatory mediators. It should be noted that immune complexes formed between either anti-neutrophil autoantibodies and their specific antigens or anti-HLA (human leucocyte antigen) antibodies and target antigens are implicated in the pathogenesis of TRALI (transfusion-related acute lung injury), and importantly, animal studies indicate that FcγRs are essential for these complexes to cause damage to the lungs. Therefore, we hypothesize that FcγRs such as FcγRIIa could contribute to the pathogenesis of ALI/ARDS.
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Haller, M., H. Forst, H. Bardenheuer, and K. Peter. "EFFECTS OF RED CELL TRANSFUSION ON SYSTEMIC OXYGEN CONSUMPTION IN SEPSIS AND ARDS." Anesthesiology 77, Supplement (September 1992): A222. http://dx.doi.org/10.1097/00000542-199209001-00222.
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Forst, H., M. Haller, H. Bardenheuer, B. Zwlssler, and K. Peter. "EFFECTS OF RED CELL TRANSFUSION ON RIGHT VENTRICULAR FUNCTION IN SEPSIS AND ARDS." Anesthesiology 77, Supplement (September 1992): A257. http://dx.doi.org/10.1097/00000542-199209001-00257.
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Kumar, Sanjeev, Gerardo Carino, Achal Dhupa, and Paul Yodice. "EXCHANGE TRANSFUSION THERAPY IN ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) DUE TO PLASMODIUM FALCIPARUM MALARIA." Chest 130, no. 4 (October 2006): 297S. http://dx.doi.org/10.1378/chest.130.4_meetingabstracts.297s-b.
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Zubrow, Michael, and Nadir Yehya. "13: RED BLOOD CELL TRANSFUSION IS ASSOCIATED WITH PROLONGED MECHANICAL VENTILATION IN PEDIATRIC ARDS." Critical Care Medicine 44, no. 12 (December 2016): 90. http://dx.doi.org/10.1097/01.ccm.0000508731.63332.70.
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Keneally, MD, Ryan J., Mark C. Hubbard, MD, Katrina Hawkins, MD, Danielle Davison, MD, and Jeffrey S. Berger, MD, MBA, FASA. "Medical planning for disaster response: Identifying risk factors for developing adult respiratory distress syndrome among trauma patients." American Journal of Disaster Medicine 16, no. 1 (January 1, 2021): 43–48. http://dx.doi.org/10.5055/ajdm.2021.0385.
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Introduction: Adult respiratory distress syndrome (ARDS) is a well-described complication of critical illness. We hypothesized that rates of comorbid diseases in a population may influence the risk for developing ARDS in trauma patients. This can help plan medical responses.Methods: Patients from the 2017 National Trauma Databank were analyzed. Inclusion criteria were an injury severity score (ISS) of ≥ 2 and 1 or more documented days of mechanical ventilation. Data were analyzed using χ2, Student’s t test, Mann–Whitney U test, or logistic regression as indicated.Results: Diabetes (odds ratio [OR] 1.33, 95 percent confidence interval [CI] 1.17-1.52), smoking (OR 1.26, 95 percent CI 1.13-1.40), transfusion (OR 1.20, 95 percent CI 1.09-1.32), ISS (OR 1.02, 95 percent CI 1.02-1.03), male gender (OR 1.22, 95 percent CI 1.10-1.35), decreasing Glasgow coma score (OR 1.04, 95 percent CI 1.03-1.05), and increasing abbreviated injury score of the thorax (OR 1.12, 95 percent CI 1.09-1.16) were associated with an increase in risk for developing ARDS.Conclusion: Diabetes and smoking are risk factors for developing ARDS after trauma. Medical response planning in countries with high rates of diabetes mellitus or smoking should take into account a greater need for intensive care and longer patient admissions to field hospitals.
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Papazian, Laurent, Pascal Thomas, Fabienne Bregeon, Louise Garbe, Christine Zandotti, Pierre Saux, Francoise Gaillat, Michel Drancourt, Jean-Pierre Auffray, and Francois Gouin. "Open-lung Biopsy in Patients with Acute Respiratory Distress Syndrome." Anesthesiology 88, no. 4 (April 1, 1998): 935–44. http://dx.doi.org/10.1097/00000542-199804000-00013.
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Background It has been suggested that fibrosis present during the fibroproliferative phase of acute respiratory distress syndrome (ARDS) can be treated by corticosteroids. However, neither clinical nor microbiologic criteria permit differentiation of this fibroproliferative phase from a nosocomial pneumonia. The aim of this observational case series was to evaluate the safety and utility of open-lung biopsy (OLB) performed in patients receiving ventilatory support who had persistent ARDS despite negative bacterial cultures. Methods During a 4-yr period, 37 OLBs were performed in 36 of 197 patients receiving ventilatory support who had ARDS. The severity of ARDS was assessed by a lung injury score of 3.1 +/- 0.4 (mean +/- SD) and a median ratio of the partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) of 118 mmHg. Histologic examination; bacterial, fungal, and acid-fast staining; and cultures of the tissue sample were performed. Results Fibrosis was present in only 41% of the lung specimens obtained by OLB. Only six patients received corticosteroids (17%). In 9 of the 15 patients with fibrosis, cytomegalovirus pneumonia precluded the use of corticosteroids. Histologic cytomegalovirus pneumonia was diagnosed in 18 cases. Histologic bacterial or mycobacterial pneumonia was diagnosed in five cases. No significant change in arterial blood gases was noted as linked to the biopsy procedure except an increase of the PaO2/FiO2 ratio. One pneumothorax was diagnosed on a chest roentgenogram 12 h after OLB. Only one patient required blood transfusion during the 48-h period after OLB (for an hemothorax). Five patients had moderate air leaks from operative chest tubes for 2-10 days. Conclusions Open lung biopsy appeared to be a useful and acceptably safe diagnostic technique in patients with ARDS. It permitted the diagnosis of unexpected cytomegalovirus pneumonia.
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Feldhaus, Danielle, Daniel Brodie, Philippe Lemaitre, Joshua Sonett, and Cara Agerstrand. "The Evolution of the Use of Extracorporeal Membrane Oxygenation in Respiratory Failure." Membranes 11, no. 7 (June 30, 2021): 491. http://dx.doi.org/10.3390/membranes11070491.
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Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency to support patients with acute respiratory failure, most commonly, and severe forms of acute respiratory distress syndrome (ARDS). The marked increase in the global use of ECMO followed the publication of a large randomized trial in 2009 and the experience garnered during the 2009 influenza A (H1N1) pandemic, and has been further supported by the release of a large, randomized clinical trial in 2018, confirming a benefit from using ECMO in patients with severe ARDS. Despite a rapid expansion of ECMO-related publications, optimal management of patients receiving ECMO, in terms of patient selection, ventilator management, anticoagulation, and transfusion strategies, is evolving. Most recently, ECMO is being utilized for an expanding variety of conditions, including for cases of severe pulmonary or cardiac failure from coronavirus disease 2019 (COVID-19). This review evaluates modern evidence for ECMO for respiratory failure and the current challenges in the field.
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Álvarez, P., R. Carrasco, C. Romero-Dapueto, and R. L. Castillo. "Transfusion-Related Acute Lung Injured (TRALI): Current Concepts." Open Respiratory Medicine Journal 9, no. 1 (June 26, 2015): 92–96. http://dx.doi.org/10.2174/1874306401509010092.
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Transfusion-related acute lung injury (TRALI) is a life-threatening intervention that develops within 6 hours of transfusion of one or more units of blood, and is an important cause of morbidity and mortality resulting from transfusion. It is necessary to dismiss other causes of acute lung injury (ALI), like sepsis, acute cardiogenic edema, acute respiratory distress syndrome (ARDS) or bacterial infection. There are two mechanisms that lead to the development of this syndrome: immune-mediated and no immune- mediated TRALI. A common theme among the experimental TRALI models is the central importance of neutrophils in mediating the early immune response, and lung vascular injury. Central clinical symptoms are dyspnea, tachypnea, tachycardia, cyanosis and pulmonary secretions, altogether with other hemodynamic alterations, such as hypotension and fever. Complementary to these clinical findings, long-term validated animal models for TRALI should allow the determination of the cellular targets for TRALI-inducing alloantibodies as well as delineation of the underlying pathogenic molecular mechanisms, and key molecular mediators of the pathology. Diagnostic criteria have been established and preventive measures have been implemented. These actions have contributed to the reduction in the overallnumber of fatalities. However, TRALI still remains a clinical problem. Any complication suspected of TRALI should immediately be reported.
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Khalid, Rabeeya, Alvin G. Thomas, Daisy Zhu, Iva Minga, Nirmit Desai, and Leonard Kaplan. "559. Outcomes of Convalescent Plasma Transfusion for SARS-CoV2 Patients in the Intensive Care Unit." Open Forum Infectious Diseases 7, Supplement_1 (October 1, 2020): S344—S345. http://dx.doi.org/10.1093/ofid/ofaa439.753.
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Abstract Background SARS-CoV2 is a grave illness and few therapeutic agents have yielded benefit or reduced mortality. Administration of convalescent plasma (CP) in viral illnesses in the past, including SARS, before day 14, has been associated with a shorter hospital course. In the present study, we are interested in determining the benefit of administering CP to critically ill patients in the intensive care unit, and the impact on mortality and other clinical markers. Methods 5 critically ill patients with confirmed SARS-CoV2 infection were observed in the uncontrolled case series study. Mechanically ventilated patients with severe ARDS (PaO2/FiO2 < 100) were eligible to receive CP transfusion. We reviewed daily vital signs, inflammatory markers, PaO2/FiO2 ratio and SOFA scores before and after CP transfusions. SARS-CoV2 PCR viral load testing was completed on day 0 of transfusion and repeated on day 3 and 6. Complications during the hospitalization and 30-day mortality were assessed. Results All 5 patients were mechanically ventilated at the time of transfusion and between day 7 to 31 of their illness. Following plasma transfusion, body temperature and inflammatory markers remained elevated in four patients (figure 1). SOFA score and PaO2/FiO2 ratios continued to worsen in three and four patients respectively (figure 2). SARS-CoV2 PCR remained positive in 4 patients. 4 of the 5 patients had died at the end of the follow up period. One patient was successfully extubated on day 29 (table 1) and discharged after a long hospital course. Fever curve and trends of inflammatory markers Trends of SOFA socre and PaO2:FiO2 ratio Patient characteristics Conclusion In our patient cohort, the administration of CP did not improve laboratory markers or clinical outcomes. Some notable limitations of this study are the small sample size, and that the patients received CP late in their disease course. Further investigation is necessary to draw definitive conclusions about the utility of CP in the treatment of SARS-CoV2. Disclosures All Authors: No reported disclosures
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Sossou, Christoph, Ogechukwu Chika-Nwosuh, Christopher Nnaoma, Jose Bustillo, Asad Chohan, Etinosasere Okundaye, and Pratik Patel. "Misdiagnosis: Acute Chest Syndrome That Evolved into Acute Respiratory Distress Syndrome in a Patient without a Documented History of Hemoglobinopathy." Case Reports in Medicine 2019 (February 3, 2019): 1–3. http://dx.doi.org/10.1155/2019/2893056.
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Acute chest syndrome (ACS) is a feared complication of sickle cell disease. Here is a case of a patient who presented with symptoms suggestive of acute chest syndrome yet had a delayed diagnosis presumably due to the lack of documented history of sickle cell disease of the patient, consequently evolving into acute respiratory distress syndrome (ARDS). He was subsequently diagnosed with heterozygous sickle cell SC disease on hemoglobin electrophoresis. After appropriate management with mechanical ventilator, broad-spectrum empiric intravenous antibiotics, exchange transfusion, and intravenous fluid resuscitation, the patient was medically optimized and safely discharged home, with significant improvement noted on successive follow-up visits.
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Haydoura, Souha, Ola Mazboudi, Khalil Charafeddine, Imad Bouakl, Tania A. Baban, Ali T. Taher, and Souha S. Kanj. "Transfusion-related Plasmodium ovale malaria complicated by acute respiratory distress syndrome (ARDS) in a non-endemic country." Parasitology International 60, no. 1 (January 2011): 114–16. http://dx.doi.org/10.1016/j.parint.2010.10.005.
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Ahmed, Adil H., Marija Kojicic, Guangxi Li, Rahul Kashyap, Sweta Thakur, Vitaly Herasevich, and Ognjen Gajic. "TRANSFUSION AS A RISK FACTOR FOR HOSPITAL-ACQUIRED ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) IN OLMSTED COUNTY MINNESOTA." Chest 136, no. 4 (October 2009): 76S. http://dx.doi.org/10.1378/chest.136.4_meetingabstracts.76s-c.
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Goins, Wendell A. "Morbidity and Mortality After Traumatic Pneumonectomy: The Effect of Compromised Oxygenation and Cardiac Function." Journal of Intensive Care Medicine 10, no. 4 (July 1995): 193–99. http://dx.doi.org/10.1177/088506669501000406.
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I describe the pathophysiological and hemodynamic events that occur after an emergency pneumonectomy for trauma and how they impact on subsequent mortality. Four patients were identified as requiring an emergency right pneumonectomy for trauma at a level 1 Urban Trauma Center within a 39-month period. A retrospective review of their hospital course served as the basis for our analysis. Three patients sustained gunshot wounds and one patient was a victim of blunt trauma. Hemodynamic data were available for three patients who survived more than 24 hours. All patients presented in shock and required massive transfusion. One patient died in the operating room due to air embolism and shock. After pneumonectomy, there was an increase in pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) more than 2 times normal, which coincided with a decrease in stroke volume, cardiac output, and right and left ventricular stroke work (RVSW/LVSW). The RVSW gradually increased to above normal levels by postoperative day 5, whereas the LVSWI remained below normal. Adult respiratory distress syndrome (ARDS) developed in all patients early in the postoperative period. There was evidence of oxygen delivery (DO2) dependent of oxygen consumption (VO2) and the DO2 remained below normal despite inotrope administration. The remaining three patients died 7 to 13 days after surgery due to various combinations of ARDS, cardiac failure, and sepsis. Until we have better methods to decrease PAP selectively, traumatic pneumonectomy should be avoided if possible, especially when it involves the right side or is associated with a contralateral lung injury. Early operative intervention and control of the pulmonary hilum may lessen the severity of shock. The hemodynamic changes that occur after pneumonectomy for trauma becomes additive in the presence of ARDS. This combination results in inadequate cardiac function, oxygen transport, and, ultimately, death.
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Auner, Birgit, Emanuel V. Geiger, Dirk Henrich, Mark Lehnert, Ingo Marzi, and Borna Relja. "Circulating Leukotriene B4 Identifies Respiratory Complications after Trauma." Mediators of Inflammation 2012 (2012): 1–8. http://dx.doi.org/10.1155/2012/536156.
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Background. Leukotriene B4 (LTB4), a proinflammatory lipid mediator correlates well with the acute phase of Acute Respiratory Distress Syndrome (ARDS). Therefore, LTB4-levels were investigated to determine whether they might be a useful clinical marker in predicting pulmonary complications (PC) in multiply traumatized patients. Methods: Plasma levels of LTB4 were determined in 100 patients on admission (ED) and for five consecutive days (daily). Twenty healthy volunteers served as control. LTB4-levels were measured by ELISA. Thirty patients developed PC (pneumonia, respiratory failure, acute lung injury (ALI), ARDS, pulmonary embolism) and 70 had no PC (ØPC).Results. LTB4-levels in the PC-group [127.8 pg/mL, IQR: 104–200pg/ml] were significantly higher compared to the ØPC-group on admission [95.6 pg/mL, IQR: 55–143 pg/mL] or control-group [58.4 pg/mL, IQR: 36–108 pg/mL]. LTB4 continuously declined to basal levels from day 1 to 5 without differences between the groups. The cutoff to predict PC was calculated at 109.6 pg/mL (72% specificity, 67% sensitivity). LTB4 was not influenced by overall or chest injury severity, age, gender or massive transfusion. Patients with PC received mechanical ventilation for a significantly longer period of time, and had prolonged intensive care unit and overall hospital stay.Conclusion. High LTB4-levels indicate risk for PC development in multiply traumatized patients.
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Ballas, Samir K. "High Mortality Among Children with Sickle Cell Anemia and Stroke Who Discontinue Chronic Blood Transfusion After Transition to An Adult Program." Blood 116, no. 21 (November 19, 2010): 1629. http://dx.doi.org/10.1182/blood.v116.21.1629.1629.
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Abstract Abstract 1629 Introduction: The Comprehensive Sickle Cell Disease study (CSCD) of 4082 patients showed that the likelihood of developing stroke was 11% by the age of 20 years for patients with sickle cell anemia (SS).The stroke prevention trials (STOP I and STOP II) in SS showed that blood transfusion prevents the occurrence of primary stroke in children with abnormal TransCranial Doppler (TCD) velocities (STOP1) and discontinuation of transfusions after 30 months resulted in a high rate of reversion to abnormal TCD velocities and stroke (STOP II). To that end all children with abnormal TCD velocities are managed with chronic blood transfusion without interruption as long as they are in pediatrics. The problem arises when they are due to be transferred to adult care after the age of 18 years. The transition process from pediatrics to adult programs is marred with several issues that often result in interruption or discontinuation of the quality care the patients had as children. There is little or no information in the literature about the outcome of children with stroke after transition to adult programs. In this study we report the outcome of 22 patients, 10 males and 12 females, with SS and stroke who were referred to our adult program from several Children's hospitals between 1993 and 2009. Patients & Methods: Records were kept prospectively. The mean age of patients at transition was 22.4 ± 3.10 years. Blood bank data were performed and computerized according to FDA and AABB regulations. Blood counts and % Hb S were done before and after each transfusion. Hb S was kept below 30% or 50% after transfusion. Metabolic profiles were done every 6 months or more often if needed. Molecular diagnostics including alpha genotypes and beta globin haplotypes were done by described methods. Statistical analysis was by the 2-tailed t test. Results: All patients had ischemic strokes during childhood and one had hemorrhagic stroke superimposed on cerebral infarction. Two patients developed moyamoya after transition. No alpha gene deletion was detected in 18 patients, 4 had one alpha gene deletion and none had 2 alpha gene deletion. The Ben/CAR haplotype was found in 7 patients, Ben/Ben in 5, Ben/Sen in 4 and other combinations in 6 patients; 21 patients were heterozygous for the Ben haplotype. Hb F was 1.0–7.0% except for one patient on hydroxyurea (HU) with 20% Hb F. All patients were kept on the same regimen of transfusion they had as children; 15 were kept on exchange transfusion two of whom were non-compliant, two were kept on simple transfusion plus HU and the remaining 5 patients refused to have chronic blood transfusion and were kept on normal care. Some of the causes for refusal were due to alloimmunization and difficult venous access. One of these 5 patients agreed to be on HU. Patients on blood exchange required an average of 55 ± 13.5 (40-98) units of RBC annually. Those on simple transfusion required up to 24 units annually. Alloimmunization was present in 10 patients with the number of alloantibodies between 1 and 6 per patient. The most common alloantibodies were ant-E and anti-K. Patients who were compliant with blood transfusion were rarely hospitalized for painful crises. Patients who were noncompliant with blood transfusion or who refused to be maintained on chronic transfusion were hospitalized for painful crises 5.7 ± 5.00 times annually (p<.025). All 5 patients who refused to be maintained on chronic blood transfusion died within 3 years after transition. Cause of death was massive intraventricular hemorrhage in one patient proven by autopsy, massive hemispheric infarct proven by imaging in the second patient leading to coma and death in the hospital and sudden death during hospitalization for painful crises in the remaining 3 patients. Two patients who were not compliant with chronic blood transfusion died within 2 years after transition due to ARDS. Thus the overall rate of death after transition was 32% and the major cause was discontinuation of chronic blood transfusion. The mean age at death was 27.0 ± 3.16 years whereas the mean age of patients who are alive is 35.4 ± 5.92 years (p<.001). Conclusion: Our data indicate that about one third of patients with SS and stroke die within 3 years after transition especially if chronic blood transfusion is discontinued or if compliance was poor. It is imperative that all efforts should be made to maintain adequate chronic blood transfusion for children with SCD and stroke after transition to adult care. Disclosures: No relevant conflicts of interest to declare.
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Serpa Neto, Ary, Nicole P. Juffermans, Sabrine N. T. Hemmes, Carmen S. V. Barbas, Martin Beiderlinden, Michelle Biehl, Ana Fernandez-Bustamante, et al. "Interaction between peri-operative blood transfusion, tidal volume, airway pressure and postoperative ARDS: an individual patient data meta-analysis." Annals of Translational Medicine 6, no. 2 (January 2018): 23. http://dx.doi.org/10.21037/atm.2018.01.16.
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Pardiwalla, Behram, Ajaykumar Yadav, Ashima Bhatia, Kedar Toraskar, Vijay Sharma, Manishkumar Shah, Ranjeet Gutte, et al. "Convalescent Plasma to Limit Coronavirus Associated Complications: A Proof of Concept Phase-2 Clinical Study at a designated COVID-19 hospital in Mumbai city." Journal of Current Medical Research and Opinion 4, no. 05 (May 8, 2021): 940–49. http://dx.doi.org/10.15520/jcmro.v4i05.419.
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Objective: With few treatment options available to manage coronavirus disease 2019 (COVID-19), health systems devised strategies to manage covid-19 using repurposed drugs and revisiting older strategies, such as convalescent plasma. This study was planned to evaluate safety and efficacy of Anti-SARS-CoV-2 convalescent plasma in hospitalized subjects with COVID-19.
Method: An open label, single centre, two arm, prospective, randomised, controlled exploratory phase 2 study was conducted at a covid-19 designated center. 20 subjects (≥18 years) were admitted to hospital (screened 15 June to 27 July 2020) with confirmed moderate covid-19 (partial pressure of oxygen in arterial blood/ fraction of inspired oxygen (PaO2/FiO2) ratio between 200 mm Hg and 300 mm Hg or a respiratory rate of more than 24/min with oxygen saturation 93% or less on room air): 10 subjects were assigned to convalescent plasma with standard treatment (test arm) and 10 subjects to standard treatment only (control arm). Subjects in the test arm received either single or two doses of convalescent plasma 24 hours apart based on their clinical condition as per investigator’s discretion.
Results: Subjects in test arm showed earlier resolution of symptoms of fever, shortness of breath and cough and the mean duration for RT-PCR test turning negative was better in the test arm. One subject in the control arm progressed to severe ARDS, while none in test arm progressed to severe ARDS. There was no difference in the use of respiratory support (invasive and non-invasive ventilation) between the 2 arms. There was no mortality observed in the study and no serious adverse reaction observed with the transfusion of convalescent plasma in the study.
Conclusion: This was an exploratory proof of concept study to explore the effectiveness of convalescent plasma in COVID-19 subjects and sample size was not large enough to detect a statistically significant difference however subjects in test arm of this study showed better outcomes in few of the efficacy parameters as compared to subjects in control arm. The use of convalescent plasma transfusion was also observed to be safe.
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Brenner, Thorsten, Johann Motsch, Jens Werner, Lars Grenacher, Eike Martin, and Stefan Hofer. "Rapid-Onset Acute Respiratory Distress Syndrome (ARDS) in a Patient Undergoing Metastatic Liver Resection: A Case Report and Review of the Literature." Anesthesiology Research and Practice 2010 (2010): 1–9. http://dx.doi.org/10.1155/2010/586425.
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Metastatic liver resection following cytoreductive chemotherapy is an accepted treatment for oligometastatic tumor diseases. Although pulmonary complications are frequently reported in patients undergoing liver surgery including liver transplantation, life-threatening acute respiratory failures in the absence of aspiration, embolism, transfusion-related acute lung injury (TRALI), pulmonary infection, or an obvious source of systemic sepsis are rare. We performed an extensive clinical review of a patient undergoing metastatic liver resection who had a clinical course compatible to an acute respiratory distress syndrome (ARDS) without an obvious cause except for the surgical procedure and multiple preoperative chemotherapies. We hypothesize that either the surgical procedure mediated by cytokines and tumor necrosis factor or possible toxic effects of oxygen applied during general anesthesia were associated with life-threatening respiratory failure in the patient. Discrete and subclinical inflammated alveoli (probably due to multiple preoperative chemotherapies with substances at potential risk for interstitial pneumonitis as well as chest radiation) might therefore be considered as risk factors.
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Russell, James A., and Keith R. Walley. "Sepsis breakthroughs in 2014." F1000Research 4 (May 28, 2015): 131. http://dx.doi.org/10.12688/f1000research.6565.1.
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The mortality of sepsis may be decreasing and, because there are more survivors, it is increasingly important to understand the epidemiology, pathogenesis, genetics, prevention, and treatment of the impaired long-term outcomes of sepsis. Recent insights on the clearance of bacterial products during sepsis suggest new strategies for early intervention. Immune suppression/immune reprogramming to decrease later secondary infections is a novel strategy now in clinical trials. The Protocolized Care for the Early Septic Shock (ProCESS), Australasian Resuscitation in Sepsis Evaluation (ARISE) and ProMISe randomized controlled trials (RCTs) of early goal-directed therapy (EGDT) versus usual care found no differences between groups in mortality. Fluid therapies may not require full-on EGDT, but rather emphasize the importance of early recognition and resuscitation of sepsis. The Albumin Italian Outcome Sepsis (ALBIOS) RCT did not find a difference between albumin (titrated to serum albumin >30 g/L) and crystalloid in severe sepsis. However, in a subgroup analysis, mortality was lower in the albumin group in patients who had septic shock. Therapeutic use of albumin may be beneficial in septic shock, but requires further evaluation in RCTs. A recent RCT of conservative versus liberal transfusion strategies (70 versus 90 g/L, respectively) found no difference in mortality in septic shock. The transfusion threshold in septic shock is now 70–90 g/L. Although there was no difference in mortality between a usual or a high target mean arterial pressure (MAP) for septic shock resuscitation, a higher MAP target may be beneficial in patients who have pre-existing hypertension, because higher MAP may decrease the incidence of acute kidney injury (AKI) and need for renal replacement therapy (RRT). Nutrition practice can continue with enteral nutrition started on days 2–3 (i.e., early but there is no indication for very early parenteral nutrition). Acute respiratory distress syndrome (ARDS) is the commonest complication of sepsis. Two recent RCTs of simvastatin and rosuvastatin in ARDS were not positive. Early statins at appropriate doses and plasma levels deserve a trial in sepsis. In future, perhaps three changes could improve the chances of having positive trials in sepsis: the use of biomarkers to stratify patients; adaptive trial design to enhance dose selection and reject compounds that are unlikely to be suitable at Phase 2; and the use of composite organ dysfunction as the primary outcome.
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Murlidharan, Jayashree, Arun Bansal, Karthi Nallasamy, and Rattiram Sharma. "A pilot randomized controlled trial comparing lower vs higher hemoglobin threshold for transfusion in children with acute Respiratory Distress Syndrome (Ards)." Journal of Pediatric Critical Care 5, no. 7 (2018): 49. http://dx.doi.org/10.21304/2018.0501.00226.
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Pérez-Jacobo, Fernando, Luis Villela Villela, Edgar Velásquez-Vega, Jesús Hernández, Melani Otañez, Mónica Arellano-Mendoza, Rosa Sosa-Camas, et al. "Phase I and Preliminary Results of a Phase II Study (TERAPLASCoV2) of Convalescent Plasma in Patients with Severe and Life-Threatening Pneumonia Caused By Sars-Cov-2." Blood 136, Supplement 1 (November 5, 2020): 30–31. http://dx.doi.org/10.1182/blood-2020-140631.
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Introduction: The current coronavirus disease- 2019 (COVID-19) pandemic has caused a sudden increase in pneumonia cases, with a case-fatality rate of 10.9% in Mexico. Two inpatient groups have been defined, with different clinical evolution: cases of severe pneumonia and those with life-threatening disease (Acute respiratory distress syndrome [ARDS], invasive mechanical ventilation [IMV] requirement, and multiorgan involvement). Currently, there is no effective treatment. Convalescent plasma (CP) has been used to treat another viral infections and outbreaks since the last century. The rationale is that neutralizing antibodies contained in CP suppress viremia and produce immunoregulation. However, an established therapeutic dose during this pandemic is lacking. Aim: To evaluate in a phase I trial the minimum effective dose of CP in severe and life-threatening disease patients and then carry out a phase II study to establish the effectiveness (overall survival at 30 days) comparing it with a non-randomized control group. Methods and design. Our study is an open-label, multicenter, non-randomized and started in May, 2020 and was approved by the ethics committee at HGE & HCN Pemex; respectively. CP donor selection: pre-donors who were infected by SARS-CoV-2 were evaluated on +30 day by serum titration (≥1:320 IgG antibody); then connected to apheresis machine to obtain 600 ml of CP that were fractionated in 200 ml bags and stored. Patients: Two groups were formed: severe and life-threating disease. CP was offered to patients who were admitted on two hospitals. Patients should meet the following criteria: SARS-CoV-2 positive for qRT- PCR, respiratory rate> 30 per minute or Kirby index <300 or IMV requirement; be older than 18 years; and sign the informed consent. Statistics: For demographic variables, the differences were evaluated with parametric or non-parametric analysis. For survival, Kaplan Meier curves were assessed for each group. A p value <0.05 was considered significant. Outcomes: A total of 110 CP bags have been transfused. The median serum IgG antibody titers were 1: 960. Dosing, phase 1. Severe group (n=14): 71% received two CP bags (400 ml) and 29% three CP bags (600 mL). Life-threatening disease group (n=10): 60% received 4 CP bags (800 ml) and 40% 3 CP bags (600 ml). Dose was established at 400 ml for the severe group and 800 ml for the life-threatening group. Security: CP infusions were well tolerated, with only 3 adverse events (2.72%) reported: one case of transfusion associated circulatory overload (TACO) that resolved with the use of loop diuretics as a serious adverse event; one fever episode (grade 1) and one case of rash (grade 1) after CP infusion. Phase II: The calculated n to be included in each arm (severe vs. life-threatening disease) is 68 and 52 patients, respectively. So far, we have included a total of 42 patients treated with CP. This entire cohort was compared with a historic group of COVID-19 patients who received other treatment strategies. Clinical characteristics on both plasma (PG) and control group (CG) are presented in table 1. We observed statistically significant differences on smoking habit, D-Dimer levels and ARDS severity between groups. The median overall follow- up was 24 days [PG 28 days vs. CG 21.5 days]. Overall Survival (OS) between PG and CG was 74% vs. 54% at 30-days respectively [HR=0.43 (C.I.95%=0.23 to 0.91, p=0.021); figure 1]. We analyzed OS by group stratification: COVID-19 severity (severe disease vs. life-threatening disease) and ARDS severity. We found no difference in OS between severe disease-PG and severe disease-CG; but we observed an OS difference between life-threatening-PG and life-threatening-CG [32% vs. 5.8% at 30-days; p=0.003]. ARDS-PG vs. ARDS-CG showed OS differences in moderate [59% vs. 25% at 30 days; p=0.01, respectively] and severe ARDS [63% vs. 0%; p=0.001, respectively]; however, there was not statistically significant difference between mild ARDS-PG and CG groups [89% vs. 86%; p=0.85, respectively]. Conclusion: This is the first phase I trial aiming to establish an effective CP dose for COVID-19 patients, at least in México. For severe and life-threatening disease, 2 and 4 CP bags were suggested. This treatment was secure, with <3% of adverse events reported. OS could be modified using certain doses based on disease severity and pa02/Fi02 index. We will continue to include patients until the calculated n is reached. Disclosures Villela: Roche: Other: advisory board, Speakers Bureau; amgen: Speakers Bureau.
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Biswas, A., R. Kumar, A. Chaterjee, and A. Pan. "A case of leptospirosis in a child with unusual clinical manifestation." Journal of College of Medical Sciences-Nepal 8, no. 2 (September 12, 2012): 37–41. http://dx.doi.org/10.3126/jcmsn.v8i2.6836.
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Leptospirosis is a re-emerging zoonotic disease with a worldwide distribution. In the mild form it may present as flu like illness. Severe form characterized by jaundice, renal dysfunction and hemorrhagic diathesis is referred to as Weil’s syndrome. Very few cases have been reported in India, and pediatric cases are extremely rare. We report a case of leptospirosis in a 12 year old girl who presented with irregular fever, malaise and spontaneous bleeding from nose. She also had headache, vomiting, subconjunctival hemorrhage, photophobia, pain abdomen, cervical lymphadenopathy, myalgia, and arthralgia. She developed severe coagulopathy, bilateral pleural effusion, ascitis, acalculous cholecystitis ultimately leading to ARDS and later multi-organ failure. ELISA for IgM leptospira was sent which came to be positive. She was given several units of packed cell, platelet concentrate, and plasma transfusion, and later mechanical ventilation and inotropic support. The patient was put on intravenous penicillin G.. which was continued for 10 days. Three weeks following admission, she had made a complete recovery and was discharged. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-2, 37-41 DOI: http://dx.doi.org/10.3126/jcmsn.v8i2.6836
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Wiktor, Arek J., Heather Carmichael, Elizabeth B. Weber, Patrick Duffy, and Anne L. Lambert Wagner. "85 Safety and Efficacy of Early Fresh Frozen Plasma Administration in Burn Resuscitation." Journal of Burn Care & Research 41, Supplement_1 (March 2020): S55—S56. http://dx.doi.org/10.1093/jbcr/iraa024.089.
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Abstract Introduction Controversy exists over the use of colloid required for burn resuscitation. Data show that fresh frozen plasma (FFP) may have benefits beyond volume sparing alone, however, there are inherent risks including transfusion related acute lung injury (TRALI) and transfusion reactions (TR). The aims of this project were: (1) determine the effectiveness of early FFP during burn resuscitation, and (2) to document any potential side effects of FFP administration. Methods A retrospective review was performed on all burn patients aged >18 years old with >20% total body surface area (TBSA) burns who underwent resuscitation using our nursing guided resuscitation protocol (NGRP) from November 2016- June 2019 at our ABA- verified burn center. Excluded were those with electrical injury, delayed resuscitation, polytrauma, renal replacement therapy and or death within 24 hours (hrs) of injury. Pursuant to the NGRP all patients with >30% TBSA burns received FFP at 6–8 hrs post injury. Data recorded included: demographics, % TBSA burned, total crystalloid/FFP, and urine output (UO). An hourly resuscitation ratio (I/O ratio) of fluid given (ml/kg/%TBSA/hr) to UO (ml/kg/hr) was calculated. FFP initiation was standardized to time zero. Major complications such as abdominal compartment syndrome (ACS), acute respiratory distress syndrome (ARDS), TRALI and TR were documented. Univariate statistical analysis was performed. Results Over the study period 71 patients required NGRP resuscitation, 56 met inclusion criteria. Baseline demographics included: 47 male (84%), median age 34 years [IQR 27–53], median TBSA 30% [range 20–95%]. 40 patients were resuscitated with FFP versus 16 patients resuscitated with crystalloid alone. Median time to FFP administration was 7 hours [IQR 6–8] with an average of 1866 ml infused [779–4484]. Those who received FFP had larger % TBSA burns median 41% [29–57] vs no FFP 22% [20–24], p< 0.001. Median I/O ratio at FFP initiation improved from 1.0 [IQR 0.4–3.7] to 0.4 [IQR 0.2–1.5, p=0.01] at 2 hrs post FFP, see Graph. Median UOP improved from 0.18 cc/kg/hr the 2 hrs prior to FFP administration, to 0.44 cc/kg/hr at 2 hrs post FFP (p=0.01). Total 24 hour fluids given (cc/kg/% TBSA) were similar in both groups: FFP 3.94 [3.49–5.36] vs no FFP 3.92 [3.54–4.53], p=0.77. There were no reported incidents of ACS, ARDS, TRALI, or TR. Conclusions The use of FFP in burn resuscitation significantly improves UOP and normalizes I/O ratios. FFP administration did not cause any serious complications. Applicability of Research to Practice Future research efforts should focus on comparing albumin vs FFP in acute burn resuscitation.
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Chowdhury, Tasmina, Abdul Basit Ibne Momen, Hironmoy Barman, Mohammad Tariqul Ahsan Khan, Kohinoor Begum, and Quazi Tarikul Islam. "Immune Thrombocytopenic Purpura With Unusual Presentations – Reports of Two Cases." Journal of Bangladesh College of Physicians and Surgeons 38, no. 4 (September 8, 2020): 218–22. http://dx.doi.org/10.3329/jbcps.v38i4.48983.
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Immune thrombocytopenic purpura (ITP) is an immune mediated bleeding disorder, usually has a relatively benign clinical course. Deep seated bleeding like intracranial haemorrhage or haemoperitonium or massive haemorrhage requiring transfusion or other intervention are rare in ITP, unless platelet count are extremely low or other complicating conditions coexist. Here are two case reports of ITP presenting in uncommon and devastating manners. The 1st one is of a 21- yearold married nulliparaous lady with ITP complicating her undiagnosed ovarian hyperstimulation syndrome leading to haemoperitonium (ruptured ovarian cyst), post operative alveolar haemorrhage resulting in ARDS and later on DVT of right leg on her 9th POD. She was managed by multi discipline team. A new consequence of her disease one after another was striking and made her management more challenging. Ultimately the lady recovered and was discharged with advice which was not less than a miracle. The 2nd case is of a 50- year- old elderly lady who had a hemorrhagic stroke as a presenting feature of ITP. Though ITP is not an uncommon disease but in these cases its presentation, consequences and severity was unusual and making its management very much challenging.
J Bangladesh Coll Phys Surg 2020; 38(4): 218-222
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Joffe, Ari Robin. "Critical Care Medicine: Major Changes in Dogma of the Past Decade." Journal of Intensive Care Medicine 16, no. 4 (July 2001): 177–92. http://dx.doi.org/10.1177/088506660101600403.
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Critical care medicine is a young specialty that has experienced an expansion of research efforts in the last decade. Many physiologic and therapeutic principles or “dogmas” have been challenged, resulting in major “shifts” and minor “drifts” in thinking. This article reviews the available literature about some of these important and sometimes controversial changes, with emphasis on the practical implications of the concepts. Specific areas discussed include supply-dependent oxygen consumption in critical illness, manipulation of the cytokine cascade in sepsis, ventilation in the acute respiratory distress syndrome (ARDS), blood transfusion in the critically ill, the concept of the multiple organ dysfunction syndrome (MODS), the need for nutritional support in the critically ill, and others. Many of the changes discussed involve the recognition that the host response to a severe insult is exceedingly complex, and the understanding of this response and the effects of it at a tissue and cellular level are incomplete. As a result, the ability to impact the outcome of sepsis and MODS has thus far been disappointing, with the possible exception of “lung-protective” ventilation. The final challenge in critical care medicine is to gain information that will allow the practitioner to better understand, prevent, and treat the complex events that result in organ and cellular dysfunction. Future changes in dogma are welcome if they help achieve these goals.
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Tanenbaum, Mira T., Anna Shvygina, Vaishnavi Sridhar, Jennifer E. Vaughn, and Mark Joseph. "Identification of the Pitfalls in the Attempted Use of Extracorporeal Membrane Oxygenation in an Adult Patient with Sickle Cell Disease and Severe Acute Chest Syndrome." Blood 134, Supplement_1 (November 13, 2019): 4854. http://dx.doi.org/10.1182/blood-2019-131561.
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BACKGROUND: Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease (SCD). Despite being the leading cause of death in adult patients with SCD, current recommendations for treatment of ACS remain largely supportive, consisting of pain management, aggressive fluid resuscitation, respiratory support, and transfusion therapy. Despite these measures, it is not uncommon for patients to require intubation due to progression to acute respiratory distress syndrome (ARDS). Recently, there have been a number of case reports that have successfully utilized extracorporeal membrane oxygenation (ECMO) for the management of ACS in those patients who fail to respond to conventional therapy [Kuo et al., 2013, Sewaralthahab et al, 2018]. However, the use of ECMO in this patient population remains uncommon, and further evaluation of this intervention is needed. This case report details an unsuccessful attempt at the use of ECMO in the case of ARDS secondary to ACS, in an attempt to identify critical pitfalls. CASE REPORT: A 32-year-old African-American female with HbSS disease on hydroxyurea therapy was transferred from an outside hospital following 3 days of respiratory decompensation. Prior to arrival, patient coded once at the outside hospital and once on transfer. Veno-arterial ECMO was initiated with improving oxygen saturation and volume status with continuous renal replacement therapy. To maintain an ECMO-specific goal hemoglobin level of 10 g/dL, 1:1 manual exchange transfusions were performed due to an inability to access equipment for automated RBC exchange. Once stable enough for CT, patient was found to have gray-white inversion suggestive of irreversible severe brain damage. Following another 28 days of supportive care with no neurologic improvement, the family decided to withdraw care, and the patient expired. CONCLUSION: While unsuccessful, this patient's case revealed a need for defining parameters regarding the initiation of ECMO in SCD patients with severe ACS. A review of previously-published literature has shown that the use of ECMO for the management of ARDS in adults is more efficacious than conventional ventilation support [Peek et al., 2009]. In patients with SCD, this improvement in efficacy is not readily reproduced, likely due to unique challenges presented by the pathophysiology of the disease. Notably, patients with SCD face additional risks of venous thromboembolism and strokes while on prolonged bed rest due to a baseline prothrombotic state [Sewaralthahab et al., 2018]. A systematic review of available case reports is needed to develop a protocol for the management of severe ACS that takes SCD-specific risks into account. The present report also makes a case for the training of providers in the early recognition of severe ACS in SCD patients. SCD remains largely undertreated in the United States, likely due to a complex interplay of patient, physician, and institutional factors. Had this patient been transferred immediately to a facility better equipped to provide a higher level of care, her condition could have arguably taken a different course. Despite the aforementioned challenges, ECMO remains a feasible option for the management of severe ACS in patients with SCD, and efforts should be made to standardize current treatment protocols. REFERENCES: Kuo KW, Cornell TT, Shanley TP, Odetola FO, and Annich GM. The use of extracorporeal membrane oxygenation in pediatric patients with sickle cell disease. Perfusion. 2013 September; 28(5): 424-432. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany M, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. The Lancet. 2009 October; 374(9698): 1351-1363. Sewaralthahab SS, Menaker J, Law JY. Successful use of veno-venous extracorporeal membrane oxygenation in an adult patient with sickle cell anemia and severe acute chest syndrome. Hemoglobin. 2018 42(1): 65-67. Disclosures No relevant conflicts of interest to declare.
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Kojicic, Marija, Emir Festic, and Ognjen Gajic. "Acute Respiratory Distress Syndrome: Insights Gained from Clinical and Translational Research." Bosnian Journal of Basic Medical Sciences 9, no. 1 (October 20, 2009): S59—S68. http://dx.doi.org/10.17305/bjbms.2009.2764.
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Acute lung injury and its more severe form acute respiratory distress syndrome (ARDS) are characterized by diffuse impairment of alveolocapillary membrane in the settings of different predisposing conditions such as sepsis, trauma and shock. Many intrahospital exposures, including aspiration, delayed resuscitation, high tidal volume mechanical ventilation and non critical use of transfusions may contribute or worsen ARDS. Therapy is targeted to treatment of predisposing condition, life supportive measures and prevention of nosocomial complications. Rigorous adherence to lung-protective mechanical ventilation is critical to prevent ventilator induced lung injury and decrease mortality. Although survival of ARDS patients has improved in the last decades ARDS mortality rates are still high and survivors encounter significant physical and psychological impairments
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Barbas, Carmen Sílvia Valente, Gustavo Faissol Janot Matos, Marcelo Britto Passos Amato, and Carlos Roberto Ribeiro Carvalho. "Goal-Oriented Respiratory Management for Critically Ill Patients with Acute Respiratory Distress Syndrome." Critical Care Research and Practice 2012 (2012): 1–13. http://dx.doi.org/10.1155/2012/952168.
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This paper, based on relevant literature articles and the authors' clinical experience, presents a goal-oriented respiratory management for critically ill patients with acute respiratory distress syndrome (ARDS) that can help improve clinicians' ability to care for these patients. Early recognition of ARDS modified risk factors and avoidance of aggravating factors during hospital stay such as nonprotective mechanical ventilation, multiple blood products transfusions, positive fluid balance, ventilator-associated pneumonia, and gastric aspiration can help decrease its incidence. An early extensive clinical, laboratory, and imaging evaluation of “at risk patients” allows a correct diagnosis of ARDS, assessment of comorbidities, and calculation of prognostic indices, so that a careful treatment can be planned. Rapid administration of antibiotics and resuscitative measures in case of sepsis and septic shock associated with protective ventilatory strategies and early short-term paralysis associated with differential ventilatory techniques (recruitment maneuvers with adequate positive end-expiratory pressure titration, prone position, and new extracorporeal membrane oxygenation techniques) in severe ARDS can help improve its prognosis. Revaluation of ARDS patients on the third day of evolution (Sequential Organ Failure Assessment (SOFA), biomarkers and response to infection therapy) allows changes in the initial treatment plans and can help decrease ARDS mortality.
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Fontana, Vincenzo, Elio Donna, Pamela Dudkiewicz, Gabriella Lander, and Yeon S. Ahn. "Interstitial Pneumonia in Patients with Idhiopatic Thrombocytopenic Purpura." Blood 104, no. 11 (November 16, 2004): 3953. http://dx.doi.org/10.1182/blood.v104.11.3953.3953.
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Abstract INTRODUCTION: Idhiopatic thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a premature destruction of platelets by macrophage, especially in the spleen. However in some cases, platelet sequestration and destruction may occur in other organs. Chromium labeled platelet sequestration study revealed that liver or precordial area are prominent sites of sequestration in some cases, suggesting that the lung might be the site in certain cases. Some cases of interstitial pneumonia are associated with immunologic injury to the lung and seen in patients with some autoimmune diseases, infections, drugs and transfusion related acute lung injury (TRALI) in which transfusions of platelets and blood products induce acute lung injury due to sequestration of platelets and neutrophils in lungs, sometimes leading to ARDS. We describe here an unusual association between ITP and interstitial pneumonia, suggesting that a lung injury similar to TRALI is involved in acute and recurrent ITP. METHODS: We have identified patients with ITP who developed interstitial pneumonia during the course of ITP. We reviewed their charts and analyzed their clinical courses of ITP and interstitial lung diseases. Laboratory tests and chest X ray or CAT scans were reviewed. The laboratory study included CBC, platelets and platelets activation was measured by PMP (platelet microparticles), expression of CD62p flowcytometrically. RESULTS: We have identified 6 patients with ITP who developed interstitial pneumonia during the course of ITP. In two of six, interstitial pneumonia was detected at the presentation of acute ITP. ITP was severe with platelet counts less than 10.000. Interstitial pneumonia was discovered incidentally by chest X ray and confirmed by CAT scans. A mild symptom of dyspnea was detected in careful examination. One underwent lung biopsy which showed findings consistent with brochiolitis obliterans organizing pneumonia. Repeated CAT scans in 1–3 months revealed marked improvement but residual interstitial infiltrates still persisted. Four others had a long standing chronic ITP with clinical courses characterized by frequent relapses in spite of surgical and medical therapy. Four of six patients had splenectomy. Interstitial lung diseases were detected at the time of a severe relapse with platelet counts of less than 20.000. One patient underwent chromium labeled platelet sequestration study which revealed rapid sequestration of platelets in the lung. Interstitial infiltrates improved following improvement of ITP but two progressed to interstitial pulmonary fibrosis. CD62P measured by flowcytometry was very high in all 3 patients tested, indicating persisting platelet activation in this clinical setting. SUMMARY: We report interstitial pneumonia developing in 6 patients with ITP. Clinically all were asymptomatic and detection of interstitial pneumonia was incidental radiology finding. A mild symptom of exertional dyspnea was present in careful investigation. Chest X ray or CT scans showed nonspecific interstitial infiltrates and showed an overall improvement within months but residual infiltrates persisted. Two progressed to pulmonary fibrosis. We suggest that platelets are sequestered and destroyed in the lung in some patients with ITP, to generate cytokines and lipid mediators that lead to a nonspecific interstitial lung disease.
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Puneet, Padmam, Shabbir Moochhala, and Madhav Bhatia. "Chemokines in acute respiratory distress syndrome." American Journal of Physiology-Lung Cellular and Molecular Physiology 288, no. 1 (January 2005): L3—L15. http://dx.doi.org/10.1152/ajplung.00405.2003.
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A characteristic feature of all inflammatory disorders is the excessive recruitment of leukocytes to the site of inflammation. The loss of control in trafficking these cells contributes to inflammatory diseases. Leukocyte recruitment is a well-orchestrated process that includes several protein families including the large cytokine subfamily of chemotactic cytokines, the chemokines. Chemokines and their receptors are involved in the pathogenesis of several diseases. Acute lung injury that clinically manifests as acute respiratory distress syndrome (ARDS) is caused by an uncontrolled systemic inflammatory response resulting from clinical events including major surgery, trauma, multiple transfusions, severe burns, pancreatitis, and sepsis. Systemic inflammatory response syndrome involves activation of alveolar macrophages and sequestered neutrophils in the lung. The clinical hallmarks of ARDS are severe hypoxemia, diffuse bilateral pulmonary infiltrates, and normal intracardiac filling pressures. The magnitude and duration of the inflammatory process may ultimately determine the outcome in patients with ARDS. Recent evidence shows that activated leukocytes and chemokines play a key role in the pathogenesis of ARDS. The expanding number of antagonists of chemokine receptors for inflammatory disorders may hold promise for new medicines to combat ARDS.
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Paulus, Elena M., Jordan A. Weinberg, Louis J. Magnotti, John P. Sharpe, Thomas J. Schroeppel, Timothy C. Fabian, and Martin A. Croce. "Admission Red Cell Distribution Width: A Novel Predictor of Massive Transfusion after Injury." American Surgeon 80, no. 7 (July 2014): 685–89. http://dx.doi.org/10.1177/000313481408000724.
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Admission red cell distribution width (aRDW) has been shown to predict mortality in trauma patients by an unclear mechanism. It has been speculated that aRDW is a marker of chronic health status, but elevated RDW may also reflect recent hemorrhage. We hypothesized that aRDW is a predictor of major hemorrhage in trauma patients. Shock trauma patients at a Level I trauma center over 6.5 years were evaluated. Patients were stratified by aRDW quintile (Q1: less than 13%, Q2: 13.1 to 13.5%, Q3: 13.6 to 14.0%, Q4: 14.1 to 14.9%, Q5: 15.0% or greater). Massive transfusion (MT) was defined as 10 or more packed red blood cells in the first 24 hours. From multiple logistic regression, odds ratios with 95 per cent confidence intervals (CIs) were determined to evaluate the association between aRDW quintile and MT. Three thousand nine hundred ninety-four met study criteria. Overall MT incidence was 10 per cent and in-hospital mortality was 17 per cent. MT and mortality increased in a stepwise fashion by aRDW quintile ( P < 0.0001). From logistic regression, a threefold increased odds of MT was associated with aRDW Q4 (CI, 1.81 to 4.92), and a 3.5-fold increased odds of MT was associated with aRDW Q5 (CI, 2.70 to 5.83). aRDW independently predicted MT, suggesting that elevated aRDW is an indicator of major hemorrhage in trauma patients. The association between aRDW and mortality in trauma patients may be explained by acute hemorrhage rather than chronic health status.
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Chiu, Li-Chung, Li-Pang Chuang, Shih-Wei Lin, Yu-Ching Chiou, Hsin-Hsien Li, Yung-Chang Chen, Yu-Jr Lin, et al. "Cumulative Fluid Balance during Extracorporeal Membrane Oxygenation and Mortality in Patients with Acute Respiratory Distress Syndrome." Membranes 11, no. 8 (July 28, 2021): 567. http://dx.doi.org/10.3390/membranes11080567.
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Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in cases of severe acute respiratory distress syndrome (ARDS) with profound hypoxemia. However, the need for high-volume fluid resuscitation and blood transfusions after ECMO initiation introduces a risk of fluid overload. Positive fluid balance is associated with mortality in critically ill patients, and conservative fluid management for ARDS patients has been shown to shorten both the duration of mechanical ventilation and time spent in intensive care, albeit without a significant effect on survival. Nonetheless, few studies have addressed the influence of fluid balance on clinical outcomes in severe ARDS patients undergoing ECMO. In the current retrospective study, we examined the impact of cumulative fluid balance (CFB) on hospital mortality in 152 cases of severe ARDS treated using ECMO. Overall hospital mortality was 53.3%, and we observed a stepwise positive correlation between CFB and the risk of death. Cox regression models revealed that CFB during the first 3 days of ECMO was independently associated with higher hospital mortality (adjusted hazard ratio 1.110 [95% CI 1.027–1.201]; p = 0.009). Our findings indicate the benefits of a conservative treatment approach to avoid fluid overload during the early phase of ECMO when dealing with severe ARDS patients.