Mitochondrial dysfunction in trauma-related coagulopathy - Is there causality? - Study protocol for a prospective observational study

Péter Jávor, Ferenc Rárosi, Tamara Horváth, László Török, Petra Hartmann, Péter Jávor, Ferenc Rárosi, Tamara Horváth, László Török, Petra Hartmann

Abstract

Hemorrhage control often poses a great challenge for clinicians due to trauma-induced coagulopathy (TIC). The pathogenesis of TIC is not completely revealed; however, growing evidence attributes a central role to altered platelet biology. The activation of thrombocytes and subsequent clot formation are highly energetic processes being tied to mitochondrial activity, and the inhibition of the electron transport chain (ETC) impedes on thrombogenesis, suggesting the potential role of mitochondria in TIC. Our present study protocol provides a guide to quantitatively characterize the derangements of mitochondrial functions in TIC. One hundred eleven severely injured (Injury Severity Score ≥16), bleeding trauma patients with an age of 18 or greater will be included in this prospective observational study. Patients receiving oral antiplatelet agents including cyclooxygenase-1 or adenosine diphosphate receptor inhibitors (aspirin, clopidogrel, prasugrel, and ticagrelor) will be excluded from the final analysis. Hemorrhage will be confirmed and assessed with computer tomography. Conventional laboratory markers of hemostasis such as prothrombin time and international normalized ratio (INR) will be measured and rotational thromboelastometry (ROTEM) will be performed directly upon patient arrival. Platelets will be isolated from venous blood samples and subjected to high-resolution fluororespirometry (Oxygraph-2k, Oroboros Instruments, Innsbruck, Austria) to evaluate the efficacy of mitochondrial respiration. Oxidative phosphorylation (OxPhos), coupling of the ETC, mitochondrial superoxide formation, mitochondrial membrane potential changes and extramitochondrial Ca2+-movement will be recorded. The association between OxPhos capacity of platelet mitochondria and numerical parameters of ROTEM aggregometry will constitute our primary outcome. The relation between OxPhos capacity and results of viscoelastic assays and conventional markers of hemostasis will serve as secondary outcomes. The association of the OxPhos capacity of platelet mitochondria upon patient arrival to the need for massive blood transfusion (MBT) and 24-hour mortality will constitute our tertiary outcomes. Mitochondrial dysfunction and its importance in TIC in are yet to be assessed for the deeper understanding of this common, life-threatening condition. Disclosure of mitochondria-mediated processes in thrombocytes may reveal new therapeutic targets in the management of hemorrhaging trauma patients, thereby leading to a reduction of potentially preventable mortality. The present protocol was registered to ClinicalTrials.gov on 12 August 2021, under the reference number NCT05004844.

Conflict of interest statement

The authors have no conflicts of interest to declare.

The Author(s). Published by S. Karger AG, Basel.

Figures

Fig. 1
Fig. 1
Protocol flowchart. a Selection and management of study participants. Patients transported directly to the Emergency Department of the University of Szeged with suspected severe injuries undergo comprehensive diagnostics including ABG, laboratory tests (including Hb, Ht, PLT, aPTT, prothrombin time (PT), and INR), extended focused assessment with sonography in trauma, and computer tomography. Severely injured (injury severity score ≥16), adult trauma patients with confirmed bleeding will be enrolled into our study. Signed informed consent from patients or their surrogates will be required for inclusion. Taking antiplatelet agents entails exclusion from the analysis. The enrolled bleeding patients will undergo ROTEM viscoelastic tests and platelet aggregometry to provide a comprehensive description on coagulative functions. b Mitochondrial measurements. Thrombocytes will be isolated from venous blood samples taken upon patient arrival and subjected to high-resolution fluororespirometry to measure the efficacy of platelet mitochondrial respiration (OxPhos) and coupling of the mitochondrial ETC. Additionally, mitochondrial membrane potential changes and extramitochondrial Ca2+ movement will also be measured in the samples. ABG, arterial blood gas analysis; eFAST, extended focused assessment with sonography in trauma; ISS, injury severity score; APA, antiplatelet agent; Hb, hemoglobin; Ht, hematocrit; PLT, platelet count.

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