End-tidal CO2 on admission is associated with hemorrhagic shock and predicts the need for massive transfusion as defined by the critical administration threshold: A pilot study

Stone, Melvin E.; Kalata, Stanley; Liveris, Anna; Adorno, Zachary; Yellin, Shira; Chao, Edward; Reddy, Srinivas H.; Jones, Michael P.; Vargas, Carlos; Teperman, Sheldon

doi:10.1016/j.injury.2016.07.007

Cited by 25 publications

(23 citation statements)

References 28 publications

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“…43 This hyperventilatory response acts to create a respiratory alkalosis by removing carbon dioxide (CO 2 ) from the blood as a way to buffer the accumulation of H þ and reduction in pH. 61 The respiratory alkalosis is reflected by concomitant reductions in end-tidal CO 2 below a threshold of 35 mmHg in both individuals in hemorrhagic shock 46 and exercising at _ VO 2 max. 47 Like respiration rate, the time kinetics of the tidal volume (V T ) response to progressively increasing intensity of exercise leading to _ VO 2 max 44,45 is similar to that reported during progressive reductions in central blood volume associated with hemorrhage and leading to decompensation.…”

Section: Physiologic Similarities Between Hemorrhagic Shock and _mentioning

confidence: 99%

“…43 This hyperventilatory response acts to create a respiratory alkalosis by removing carbon dioxide (CO 2 ) from the blood as a way to buffer the accumulation of H + and reduction in pH. 61 The respiratory alkalosis is reflected by concomitant reductions in end-tidal CO 2 below a threshold of 35 mmHg in both individuals in hemorrhagic shock 46 and exercising at trueV˙O 2 max. 47…”

Section: Absolute Vs Relative Hypovolemiamentioning

confidence: 99%

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Physiological comparison of hemorrhagic shock and V˙O₂max: A conceptual framework for defining the limitation of oxygen delivery

Convertino

Lye

Koons

et al. 2019

Exp Biol Med (Maywood)

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Based on evidence extracted from a cross-sectional review of the literature, we sought to advance a novel conceptual framework that the physiology of hemorrhagic shock from exsanguination and maximal oxygen uptake ([Formula: see text]O2max), induced by physical exercise, shares key common features. As such, this review focuses on the notion that intolerance to inadequate oxygen delivery (DO2) resulting from associated states of hypovolemia appears to be a common physiological link that “connects” hemorrhagic shock to the physiology that limits maximal aerobic capacity. Our approach focuses on the similarities in a complex cascade of cardiopulmonary, metabolic and autonomic compensatory responses during hemorrhage and maximal physical exertion that ultimately function to avoid critical levels of DO2 (DO2crit) and are manifested by elevation in blood lactate levels. We introduce a paradigm of absolute (i.e. hemorrhage) versus relative (i.e. exercise) hypovolemia as a primary physiological factor that contributes to reaching DO2crit, and define the concept of “O2 deficit” to replace the clinical concept of O2 debt. Using the peer-reviewed literature, we provide human data obtained from patients who suffered hemorrhagic shock from severe blood loss and compare it to healthy subjects who performed maximal exercise. We include a novel conceptual framework of the continuum of metabolic relationship between DO2 and [Formula: see text]O2 that is manifested as the final step during both progressive blood loss leading to hemorrhagic shock and at [Formula: see text]O2max. We present evidence to support the contribution of utilizing “O2 extraction reserve” as the initial mechanism for developing an O2 deficit, and the notion of individual variability in compensatory responses. In the absence of reversing inadequate DO2, an increased reliance on O2 extraction reserve, cellular anaerobic glycolysis, and phosphocreatine stores to supplement the energy required by the tissues for normal function will deplete a finite capacity for compensation. In the end, acidity reflected by a blood pH ≤ ∼7.0 leads to disturbance of normal cell functioning of metabolic machinery manifested by irreversible shock in the case of hemorrhage or physical exhaustion when [Formula: see text]O2max is reached. Impact statement Disturbance of normal homeostasis occurs when oxygen delivery and energy stores to the body’s tissues fail to meet the energy requirement of cells. The work submitted in this review is important because it advances the understanding of inadequate oxygen delivery as it relates to early diagnosis and treatment of circulatory shock and its relationship to disturbance of normal functioning of cellular metabolism in life-threatening conditions of hemorrhage. We explored data from the clinical and exercise literature to construct for the first time a conceptual framework for defining the limitation of inadequate delivery of oxygen by comparing the physiology of hemorrhagic shock caused by severe blood loss to maximal oxygen uptake induced by intense physical exercise. We also provide a translational framework in which understanding the fundamental relationship between the body’s reserve to compensate for conditions of inadequate oxygen delivery as a limiting factor to [Formula: see text]O2max helps to re-evaluate paradigms of triage for improved monitoring of accurate resuscitation in patients suffering from hemorrhagic shock.

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Section: Physiologic Similarities Between Hemorrhagic Shock and _mentioning

confidence: 99%

Section: Absolute Vs Relative Hypovolemiamentioning

confidence: 99%

Physiological comparison of hemorrhagic shock and V˙O₂max: A conceptual framework for defining the limitation of oxygen delivery

Convertino

Lye

Koons

et al. 2019

Exp Biol Med (Maywood)

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“…In this study, CAT+ showed the best sensitivity and RI+ showed better specificity with good positive predictive value. Another study,23 which had CAT outcomes, was a pilot study that had a small sample size.…”

Section: Discussionmentioning

confidence: 99%

“…Data from all eligible studies were extracted by two individual authors. Extracted data from each of the eligible studies included the following3691012131415161718192021222324: first author's name; year of publication; study location; study design; study period; number of patients analyzed; and patients' ages, ISS, and mortality with and without MT. In addition, the number of true positives, false positives, false negatives, and true negatives for each MT (≥ 10 pRBC/24 hours), CAT (≥ 3 pRBC/1 hour), and RI (≥ 4 units) were investigated to obtain the sensitivity, specificity, diagnostic odds ratio (OR), and summary receiver operating characteristic (SROC) curve.…”

Section: Methodsmentioning

confidence: 99%

Prognostic Accuracy of Massive Transfusion, Critical Administration Threshold, and Resuscitation Intensity in Assessing Mortality in Traumatic Patients with Severe Hemorrhage: a Meta-Analysis

et al. 2019

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Background: The aim of this study was to assess the prognostic value of massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI) for the mortality of trauma patients with severe hemorrhage. Methods: Seventeen relevant articles were obtained by searching the PubMed databases through February 15, 2019. The estimated mortality rates and injury severity scores were obtained through a meta-analysis. In addition, diagnostic test accuracy (DTA) reviews were conducted to obtain the sensitivity, specificity, diagnostic odds ratio, and the summary receiver operating characteristic curve. Results: At 24 hours, the estimated mortality rates were 0.194, 0.126, and 0.168 in assessments using MT, CAT, and RI, respectively. In addition, the pooled sensitivity of CAT (0.89; 95% confidence interval [CI], 0.82-0.94) was significantly higher than that of MT (0.63; 95% CI, 0.57-0.68) and RI (0.69; 95% CI, 0.63-0.75). Overall, the pooled specificity of MT and CAT was 0.82 (95% CI, 0.80-0.83) and 0.85 (95% CI, 0.83-0.88), respectively, while the pooled sensitivity was 0.49 (95% CI, 0.44-0.54) and 0.50 (95% CI, 0.38-0.62), respectively. Conclusion: CAT may be a more sensitive predictor for 24-hour mortality than other predictors. Furthermore, RI also appears to be a useful predictor for 24-hour mortality. Both MT and CAT showed high specificity for overall mortality.

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“…[15][16][17] The relationship between abnormally low ETCO 2 and trauma patient outcomes is present in numerous prehospital, emergency department, and operating-room-based studies. [18][19][20][21][22][23][24][25][26]…”

Section: Design and Settingmentioning

confidence: 99%

Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion

Mapp

Bank²,

Osborn

et al. 2019

Prehosp. Disaster med.

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Introduction:In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs.Methods:The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative.Results:Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS.Conclusion:This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.

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End-tidal CO2 on admission is associated with hemorrhagic shock and predicts the need for massive transfusion as defined by the critical administration threshold: A pilot study

Cited by 25 publications

References 28 publications

Physiological comparison of hemorrhagic shock and V˙O₂max: A conceptual framework for defining the limitation of oxygen delivery

Physiological comparison of hemorrhagic shock and V˙O₂max: A conceptual framework for defining the limitation of oxygen delivery

Prognostic Accuracy of Massive Transfusion, Critical Administration Threshold, and Resuscitation Intensity in Assessing Mortality in Traumatic Patients with Severe Hemorrhage: a Meta-Analysis

Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion

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End-tidal CO2 on admission is associated with hemorrhagic shock and predicts the need for massive transfusion as defined by the critical administration threshold: A pilot study

Cited by 25 publications

References 28 publications

Physiological comparison of hemorrhagic shock and V˙O2max: A conceptual framework for defining the limitation of oxygen delivery

Physiological comparison of hemorrhagic shock and V˙O2max: A conceptual framework for defining the limitation of oxygen delivery

Prognostic Accuracy of Massive Transfusion, Critical Administration Threshold, and Resuscitation Intensity in Assessing Mortality in Traumatic Patients with Severe Hemorrhage: a Meta-Analysis

Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion

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Physiological comparison of hemorrhagic shock and V˙O₂max: A conceptual framework for defining the limitation of oxygen delivery

Physiological comparison of hemorrhagic shock and V˙O₂max: A conceptual framework for defining the limitation of oxygen delivery