Connor M. Bunch

Rhabdomyolysis is a potentially life-threatening syndrome characterized by skeletal muscle breakdown and release of intracellular contents into circulation, which can result in electrolyte abnormalities, acute kidney injury (AKI), and renal failure. Viral infections, particularly influenza, are recognized triggers of rhabdomyolysis; however, recurrent or unusually severe presentations may suggest underlying genetic susceptibility. We report a case of a previously healthy 21-year-old male with a prior history of COVID-19-associated rhabdomyolysis who presented to the emergency department with fever, generalized weakness, myalgia, red urine, and decreased oral intake following influenza A infection. Laboratory evaluation demonstrated severe rhabdomyolysis with creatine kinase (CK) elevation from 512,650 IU/L to a peak of over 1,000,000 IU/L, complicated by pigment-induced AKI requiring temporary hemodialysis. Extensive autoimmune, metabolic, and neuromuscular evaluation was unremarkable. Subsequent genetic testing identified a heterozygous pathogenic STAC3 variant and variants of uncertain significance in SCN4A, PLEC, and MYH7, raising suspicion for an underlying inherited predisposition to recurrent viral-induced muscle injury. This case highlights the importance of considering genetic susceptibility in patients with recurrent or severe viral-induced rhabdomyolysis, particularly in the setting of extreme CK elevation and recurrent episodes.

Background/Objectives: The United States is facing a national blood shortage, which is a function of the reduced number of donors since the COVID-19 pandemic and the increasing use of balanced hemostatic resuscitation for severely bleeding trauma patients. As a result, recent attempts to define futility based on clinical and laboratory criteria have been proposed. There is no literature on the frequency of institutional futility protocols, either at hospitals or blood collection centers. Methods: The Association for the Advancement of Blood & Biotherapies sent out a survey to 800 United States hospitals and blood collection centers to determine the frequency of trauma futility protocols and the need to limit blood for non-trauma patients due to high use in trauma patients. Results: 213 (26.6%) institutions responded. 10.8% of hospitals and blood collection centers reported having a trauma futility protocol, and those hospitals and blood collection centers with futility protocols were more likely to have needed to limit blood to non-trauma patients due to high consumption by trauma patients. Conclusions: Trauma futility protocols at hospitals and blood collection centers are uncommon. Because of the national shortage of blood products available for trauma and non-trauma cases, implementing institutional trauma futility protocols may help to curb the incidence of blood limitation to non-trauma patients. Increased awareness and communication between blood bankers and traumatologists during the declaration of futility may reduce blood wastage and enhance the nation’s blood supply reservoirs.

Bleeding patients in the medical intensive care unit (MICU) are often coagulopathic, yet the best way to guide blood product resuscitation for the critically ill is not settled. Viscoelastic tests, such as thromboelastography (TEG), are increasingly used by intensivists to guide resuscitation and restore hemostasis. We performed a retrospective study of patients admitted to the MICU at a single tertiary care center in Detroit, Michigan, USA, with a high prevalence of decompensated cirrhosis and septic shock. The historical cohort included patients prior to TEG being available in the MICU. The observational cohort included data where TEG was available and applied in our MICU to guide blood product use. Patients were included if they were an adult > 18 years of age with an initial admission to Henry Ford Hospital MICU who received any blood component therapy. A total of 927 patients met inclusion criteria with 487 (52.5%) patients in the historical cohort and 440 (47.5%) in the observational cohort. Compared with the historical cohort, patients of the observational cohort were administered significantly less plasma (658.3 mL/patient (IQR = 931) vs. 410.8 mL/patient (IQR = 381), p < 0.001). There was no significant difference in mortality (54.4% vs. 50.5%, p = 0.408) or hospital length of stay (LOS) (13 days vs. 14 days, p = 0.08). In a generalized MICU population, the introduction of TEG‐guided blood component resuscitation was associated with conserved plasma without significant effect on mortality or LOS. No causation can be drawn to TEG from the retrospective nature of this study. However, this study provides impetus to further study blood product stewardship potentially derived from viscoelastic test‐guided transfusions in a general MICU population.

Background/Objectives: The timely evaluation of blood clot formation and breakdown is essential in the care of patients with severe bleeding or critical illness. Resonant acoustic rheometry is a novel, non-contact ultrasound method that measures changes in the viscoelastic properties of blood in a standard microplate format. Here, we present the first clinical description of whole blood coagulation and fibrinolysis assessed with resonant acoustic rheometry, with paired thromboelastography measurements for comparison. Methods: In this retrospective analysis, whole blood samples from three critically ill patients were divided and tested under four different conditions that included a control mixture, kaolin activation, tissue factor activation, and a tissue factor mixture supplemented with tissue plasminogen activator. The resonant acoustic rheometry system obtained real time measurements of resonant surface waves and displacements from the samples. Heat maps and spectrograms of the resonant surface waves were analyzed to determine the onset of clotting, the rate of viscoelastic stiffening, the time to maximum rigidity, and the onset as well as magnitude of fibrinolysis. These measurements were compared with thromboelastography reaction time, clot strength, fibrinogen contribution, and lysis values. Results: Resonant acoustic rheometry detected reproducible transitions from liquid to clot and from clot to lysis in all samples. Activator-dependent changes in clot initiation and propagation matched the expected hierarchy observed in thromboelastography. Significantly, samples exposed to tissue plasminogen activator demonstrated a clear fall in resonant frequency and a corresponding rise in surface displacement that reflected fibrinolysis. The technique also reproduced clinically meaningful patterns of hemostasis that aligned with each patient’s underlying disease. Conclusions: Whole blood clotting can be measured with resonant acoustic rheometry in a manner that aligns with established clinical assays. These results suggest strong potential for future use of resonant acoustic rheometry as a cost-effective, complementary platform for rapid, scalable, and clinically informative hemostatic assessment.

Roux-en-Y gastric bypass (RYGB) is a widely performed bariatric procedure that rarely leads to complications involving the remnant stomach. We present the case of severe gastric outlet obstruction caused by ulceration in the remnant stomach 2 decades after RYGB. Multimodal imaging confirmed the diagnosis, with direct visualization achieved via access through a gastrostomy-tube tract. This case highlights the importance of sustained clinical vigilance with the possibility of late-onset complications of RYGB, such as remnant gastric ulcers, which may manifest long after the routine postprocedural follow-up period.

In the trauma resuscitation literature, there are inconsistent definitions of what constitutes massive transfusion and a unit of blood, complicating the use of transfusion cut-points to declare futility. This is problematic as it can lead to the inefficient use of blood products, further exacerbating current blood product shortages. Previous studies have used various transfusion cut-points per hour to define futility in retrospective analyses but have not accurately defined futility at the bedside due to patient survival even at large rates and volumes of blood transfused. In an attempt to use transfusion cut-points as a marker to help define futility, guidelines have been proposed to limit blood product waste in transfusions for severely bleeding trauma patients, such as Suspension of Transfusion and Other Procedures (STOP) for patients older than 15 and the Futility of Resuscitation Measure (FoRM), used to determine futility in patients older than 60. In an effort to construct effective bedside futile resuscitation criteria with 100% positive predictive value and specificity, this review proposes the use of specific blood component transfusion cut-points combined with parameters from both STOP and FoRM to allow for a comprehensive and accurate method of declaring futility in severely bleeding trauma patients.

The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility.

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.