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Earle SA, de Moya MA, Zuccarelli JE, Norenberg MD, Proctor KG. Cerebrovascular resuscitation after polytrauma and fluid restriction. J Am Coll Surg 2007; 204:261-75. [PMID: 17254930 DOI: 10.1016/j.jamcollsurg.2006.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 11/16/2006] [Accepted: 11/16/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are few reproducible models of blast injury, so it is difficult to evaluate new or existing therapies. We developed a clinically relevant polytrauma model to test the hypothesis that cerebrovascular resuscitation is optimized when intravenous fluid is restricted. STUDY DESIGN Anesthetized swine (42+/-5 kg, n=35) received blasts to the head and bilateral chests with captive bolt guns, followed by hypoventilation (4 breaths/min; FiO(2)=0.21). After 30 minutes, resuscitation was divided into phases to simulate typical prehospital, emergency room, and ICU care. For 30 to 45 minutes, group 1, the control group (n=5), received 1L of normal saline (NS). For 45 to 120 minutes, additional NS was titrated to mean arterial pressure (MAP) > 60 mmHg. After 120 minutes, mannitol (1g/kg) and phenylephrine were administered to manage cerebral perfusion pressure (CPP) > 70 mmHg, plus additional NS was given to maintain central venous pressure (CVP) > 12 mmHg. In group 2 (n=5), MAP and CPP targets were the same, but the CVP target was>8 mmHg. Group 3 (n=5) received 1 L of NS followed only by CPP management. Group 4 (n=5) received Hextend (Abbott Laboratories), instead of NS, to the same MAP and CPP targets as group 2. RESULTS Polytrauma caused 13 deaths in the 35 animals. In survivors, at 30 minutes, MAP was 60 to 65 mmHg, heart rate was >100 beats/min, PaO(2) was < 50 mmHg, and lactate was>5 mmol/L. In two experiments, no fluid or pressor was administered; the tachycardia and hypotension persisted. The first liter of intravenous fluid partially corrected these variables, and also partially corrected mixed venous O(2), gastric and portal venous O(2), cardiac output, renal blood flow, and urine output. Additional NS (total of 36+/-1 mL/kg/h and 17+/-6 mL/kg/h, in groups 1 and 2, respectively) correlated with increased intracranial pressure to 38+/-4 mmHg (group 1) and 26+/-4 mmHg (group 2) versus 22+/-4 mmHg in group 3 (who received 5+/-1 mL/kg/h). CPP was maintained only after mannitol and phenylephrine. By 5 hours, brain tissue PO(2) was>20 mmHg in groups 1 and 2, but only 6+/-1 mmHg in group 3. In contrast, minimal Hextend (6+/-3 mL/kg/h) was needed; the corrections in MAP and CPP were immediate and sustained, intracranial pressure was lower (14+/-2 mmHg), and brain tissue PO(2) was> 20 mmHg. Neuropathologic changes were consistent with traumatic brain injury, but there were no statistically significant differences between groups. CONCLUSIONS After polytrauma and resuscitation to standard MAP and CPP targets with mannitol and pressor therapy, we concluded that intracranial hypertension was attenuated and brain oxygenation was maintained with intravenous fluid restriction; cerebrovascular resuscitation was optimized with Hextend versus NS; and longer term studies are needed to determine neuropathologic consequences.
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King DR, Patel MB, Feinstein AJ, Earle SA, Topp RF, Proctor KG. Simulation training for a mass casualty incident: two-year experience at the Army Trauma Training Center. ACTA ACUST UNITED AC 2006; 61:943-8. [PMID: 17033566 DOI: 10.1097/01.ta.0000233670.97515.3a] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Civilian and military mass casualty incidents (MCI) are an unfortunate reality in the 21st century, but there are few situational training exercises (STX) to prepare for them. To fill this gap, we developed a MCI STX for U.S. Army Forward Surgical Teams (FST) in conjunction with the U.S. Army Trauma Training Center. METHODS After a standardized briefing, each FST has 60 minutes to unpack, setup, and organize a standard equipment cache into an emergency room, operating room, and intensive care unit. In an adjacent room, five anesthetized swine are prepared with standardized, combat-relevant injuries. The number and acuity of the total casualties are unknown to the FST and arrive in waves and without warning. A realistic combat environment is simulated by creating resource limitations, power outages, security breaches, and other stressors. The STX concludes when all casualties have died or are successfully treated. FSTs complete a teamwork self-assessment card, while staff and FST surgeons evaluate organization, resource allocation, communication, treatment, and overall performance. Feedback from each FST can be incorporated into an updated design for the next STX. RESULTS From 2003-2005, 16 FSTs have completed the STX. All FSTs have had collapses in situational triage, primary/ secondary surveys, and/or ATLS principles (basic ABCs), resulting in approximately 20% preventable deaths. CONCLUSIONS We concluded (1) a MCI can overwhelm even combat- experienced FSTs; (2) adherence to basic principles of emergency trauma care by all FST members is essential to effectively and efficiently respond to this MCI; (3) by prospectively identifying deficiencies, future military or civilian performance during an actual MCI may be improved; and (4) this MCI STX could provide a template for similar programs to develop, train, and evaluate civilian surgical disaster response teams.
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Patel MB, Proctor KG, Majetschak M. Extracellular ubiquitin increases in packed red blood cell units during storage. J Surg Res 2006; 135:226-32. [PMID: 16926027 DOI: 10.1016/j.jss.2006.04.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 04/21/2006] [Accepted: 04/26/2006] [Indexed: 01/04/2023]
Abstract
BACKGROUND Ubiquitin (Ub) is involved in intracellular protein metabolism, but may also have extracellular roles in host defense and immunomodulation. Erythrocytes contain high amounts of Ub and hemolysis is one potential source of extracellular Ub in vivo. Since hemolysis also occurs with storage of packed RBC units (pRBCs) in vitro, we hypothesized that Ub is released during storage and that it correlates with immunological properties of pRBCs. MATERIALS AND METHODS Daily aliquots were drawn from pRBCs (n = 3) for 42 days and plasma was isolated. Ub was measured by ELISA. Immunomodulatory properties of plasma were assessed by measuring endotoxin-stimulated cytokine (TNF-alpha, IL-6, IL-8) production of normal whole blood, and cell proliferation in phytohemagglutinin-stimulated peripheral blood mononuclear cells. RESULTS Plasma Ub linearly increased (49 +/- 2 ng/mL/day; r(2) = 0.82, P < 0.001) 20-fold to 2170 +/- 268 ng/mL on day 42. Plasma inhibited TNF-alpha production but stimulated IL-8 production of normal whole blood, which correlated with time-dependent Ub release (TNFalpha: r(spearman) = -0.626, P < 0.001; IL-8: r(spearman) = 0.427, P = 0.004). Addition of exogenous Ub (equaling day 42 concentration) to day 0-4 plasma inhibited TNF-alpha production by one-third of the effect detected for day 42 plasma, but also inhibited IL-8 production by 40%. IL-6 production and cell proliferation was unchanged between day 0-4 plasma with or without Ub supplementation and day 42 plasma. CONCLUSIONS Extracellular Ub release in pRBCs correlates with in vitro immunomodulatory effects and may partially contribute to transfusion-related immune modulation. Additionally, the linear kinetics of the ubiquitin release during pRBC storage suggest Ub is a suitable in vitro quality control parameter.
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Patel MB, Feinstein AJ, Saenz AD, Majetschak M, Proctor KG. Prehospital HBOC-201 after traumatic brain injury and hemorrhagic shock in swine. ACTA ACUST UNITED AC 2006; 61:46-56. [PMID: 16832248 DOI: 10.1097/01.ta.0000219730.71206.3a] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Data are limited on the actions of hemoglobin based oxygen carriers (HBOCs) after traumatic brain injury (TBI). This study evaluates neurotoxicity, vasoactivity, cardiac toxicity, and inflammatory activity of HBOC-201 (Biopure, Cambridge, Mass.) resuscitation in a TBI model. METHODS Swine received TBI and hemorrhage. After 30 minutes, resuscitation was initiated with 10 mL/kg normal saline (NS), followed by either HBOC-201 (6 mL/kg, n = 10) or NS control (n = 10). Supplemental NS was administered to both groups to maintain mean arterial pressure (MAP) >60 mm Hg until 60 minutes, and to maintain cerebral perfusion pressure (CPP) >70 mm Hg from 60 to 300 minutes. The control group received mannitol (1 g/kg) and blood (10 mL/kg) at 90 minutes and half (n = 5) received CPP directed phenylephrine (PE) therapy after 120 minutes. Serum cytokines were measured with ELISA and coagulation was evaluated with thromboelastography. Brains were harvested for neuropathology. RESULTS With HBOC administration, MAP, CPP, and brain tissue PO2 were restored within 30 minutes and maintained until 300 minutes. Clot strength and fibrin formation were maintained and 9/10 successfully extubated. In contrast, with control, MAP and brain tissue PO2 did not correct until 120 minutes, after mannitol, transfusion and 40% more crystalloid. Furthermore, without PE, CPP did not reach target and 0/5 could be extubated. Lactate, heart rate, cardiac output, mixed venous oxygenation, muscle oxygenation, serum cytokines, and histology did not differ between groups. CONCLUSIONS After TBI, a single HBOC-201 bolus with minimal supplements provided rapid resuscitation, while maintaining CPP and improving brain oxygenation, without causing cardiac dysfunction, coagulopathy, cytokine release, or brain structural changes.
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Sanui M, King DR, Feinstein AJ, Varon AJ, Cohn SM, Proctor KG. Effects of arginine vasopressin during resuscitation from hemorrhagic hypotension after traumatic brain injury. Crit Care Med 2006; 34:433-8. [PMID: 16424725 DOI: 10.1097/01.ccm.0000196206.83534.39] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Two series of experiments were designed to evaluate whether early arginine vasopressin improves acute outcome following resuscitation from traumatic brain injury and severe hemorrhagic hypotension. DESIGN Prospective randomized, blinded animal study. SETTING University laboratory. SUBJECTS Thirty-three swine. INTERVENTIONS In series 1 (n = 19), after traumatic brain injury with hemorrhage and 12 mins of shock (mean arterial pressure approximately 20 mm Hg), survivors (n = 16) were initially resuscitated with 10 mL/kg crystalloid. After 30 mins, crystalloid and blood with either 0.1 unit x kg(-1) x hr(-1) arginine vasopressin or placebo was titrated to a mean arterial pressure target >or=60 mm Hg. After 90 mins, all received mannitol and the target was cerebral perfusion pressure >or=60 mm Hg. To test cerebrovascular function, 7.5% inhaled CO2 was administered periodically. In series 2 (n = 14), the identical protocol was followed except the shock period was 20 mins and survivors (n = 10) received a bolus of either arginine vasopressin (0.2 units/kg) or placebo during the initial fluid resuscitation. MEASUREMENTS AND MAIN RESULTS In series 1, by 300 mins after traumatic brain injury with arginine vasopressin (n = 8) vs. placebo (n = 8), the fluid and transfusion requirements were reduced (both p < .01), intracranial pressure was improved (11 +/- 1 vs. 23 +/- 2 mmHg; p < .0001), and the CO2-evoked intracranial pressure elevation was reduced (7 +/- 2 vs. 26 +/- 3 mm Hg, p < .001), suggesting improved compliance. In series 2, with arginine vasopressin vs. placebo, cerebral perfusion pressure was more rapidly corrected (p < .05). With arginine vasopressin, five of five animals survived 300 mins, whereas three of five placebo animals died. The survival time with placebo was 54 +/- 4 mins (p < .05 vs. arginine vasopressin). CONCLUSIONS Early supplemental arginine vasopressin rapidly corrected cerebral perfusion pressure, improved cerebrovascular compliance, and prevented circulatory collapse during fluid resuscitation of hemorrhagic shock after traumatic brain injury.
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King DR, Cohn SM, Feinstein AJ, Proctor KG. Systemic coagulation changes caused by pulmonary artery catheters: laboratory findings and clinical correlation. ACTA ACUST UNITED AC 2006; 59:853-7; discussion 857-9. [PMID: 16374273 DOI: 10.1097/01.ta.0000187656.26849.39] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A higher rate of pulmonary embolism has been associated with pulmonary artery (PA) catheters; however, no mechanism has been described. Conventional tests of coagulation reveal no changes related to PA catheterization. The purpose of this study was to determine whether PA catheterization resulted in a hypercoagulable state detectable by thrombelastography (TEG). METHODS ANIMAL Healthy, anesthetized, swine (n = 19) underwent PA catheterization. Samples were drawn from 7F femoral arterial catheters before and two hours after PA catheterization, at 5 mL/min, and analyzed (native whole blood, n = 15, kaolin activated blood, n = 4) by TEG (Hemoscope, Niles, IL) at precisely two minutes. Human: An IRB-approved prospective, observational trial was conducted in critically ill patients (n = 19). Samples were drawn from 22-gauge radial artery catheters, before and three hours after PA catheterization. Kaolin-activated TEG samples were analyzed at precisely five minutes. Data are mean +/- SE; Groups were compared with analysis of variance and significance was assessed at the 95% confidence interval. RESULTS In both animals and patients, PA catheterization truncated R times (time to initial fibrin formation). In swine, the R times were 17.6 +/- 1.3 minutes (native) and 3.8 +/- 0.4 (kaolin) before PA catheterization, and decreased to 6.3 +/- 1.0 minutes (p = 0.002) and 1.9 +/- 0.5 minutes (p = 0.010) afterward. There were no changes in pH or temperature during the experiment. In patients, 4 of 19 were excluded for protocol violations. The R time was 6.3 +/- 1.0 minutes (kaolin) before and 3.0 +/- 0.3 minutes after catheterization (p = 0.003). No changes were observed in conventional coagulation parameters, temperature or pH. CONCLUSION In healthy swine, and critically ill patients, PA catheters may enhance thrombin formation and fibrin polymerization, indicating a systemic hypercoagulable state. This may explain why PA catheters are associated with an increased risk of pulmonary emboli.
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Feinstein AJ, Patel MB, Sanui M, Cohn SM, Majetschak M, Proctor KG. Resuscitation with Pressors after Traumatic Brain Injury. J Am Coll Surg 2005; 201:536-45. [PMID: 16183491 DOI: 10.1016/j.jamcollsurg.2005.05.031] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Revised: 04/27/2005] [Accepted: 05/20/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND The purpose of the study was to compare initial resuscitation with arginine vasopressin (AVP), phenylephrine (PE), or isotonic crystalloid fluid alone after traumatic brain injury and vasodilatory shock. STUDY DESIGN Anesthetized, ventilated swine (n = 39, 30 +/- 2 kg) underwent fluid percussion traumatic brain injury followed by hemorrhage (30 +/- 2mL/kg) to a mean arterial pressure < 30mmHg, then were randomized to 1 of 5 groups to maintain mean arterial pressure > 60mmHg for 30 to 60minutes, then cerebral perfusion pressure > 60mmHg for 60 to 300minutes, either unlimited crystalloid fluid only (n = 9), arginine vasopressin + fluid (n = 9), phenylephrine + fluid (n = 9), arginine vasopressin only (n = 5), or phenylephrine only (n = 5). Heterologous transfusions were administered if hematocrit was < 13, and mannitol was administered if intracranial pressure was > 20 mmHg. Cerebrovascular reactivity was evaluated with serial CO(2) challenges. RESULTS In all groups, physiologic variables were similar at baseline and at the end of shock. On resuscitation, all achieved mean arterial pressure and cerebral perfusion pressure goals. Brain tissue PO(2)s were similar. With fluid only, more blood and mannitol were required, intracranial pressure and peak inspiratory pressure were higher, and cerebrovascular reactivity was decreased (all p < 0.05 versus pressor + fluid). With either pressor + fluid, cardiac output, heart rate, lactate, and mixed venous O(2) saturation were similar to fluid only, but total fluid requirements and urine output were both reduced (p < 0.05). With either pressor only, intracranial pressure remained low, but mixed venous O(2) saturation, cardiac output, and urine output were decreased (all p < 0.05 versus other groups). CONCLUSIONS To correct vasodilatory shock after traumatic brain injury, a resuscitation strategy that combined either phenylephrine or arginine vasopressin plus crystalloid was superior to either fluid alone or pressor alone.
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Feinstein AJ, Cohn SM, King DR, Sanui M, Proctor KG. Early Vasopressin Improves Short-Term Survival after Pulmonary Contusion. ACTA ACUST UNITED AC 2005; 59:876-82; discussion 882-3. [PMID: 16374276 DOI: 10.1097/01.ta.0000187654.24146.22] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Arginine vasopressin (AVP) is a promising treatment for several types of irreversible shock, but its therapeutic potential has not been examined after severe chest trauma. Two series of experiments were performed to fill this gap. METHODS Series 1: anesthetized, mechanically-ventilated pigs (n = 20, 29 +/- 1 kg) received a blast to the chest, followed by a "controlled" arterial hemorrhage to a mean arterial pressure (MAP) <30 mm Hg. At 20 minutes, a 10 mL/kg normal saline (NS) bolus was followed by either 0.1 U/kg AVP bolus or NS, in randomized, blinded fashion. From 30-300 minutes, either AVP (0.4 U/kg/hr plus NS) or NS alone was infused as needed to MAP>70 mm Hg. Series 2: Swine (n = 15) received the chest injury followed by partial left hepatectomy to produce "uncontrolled" hemorrhage. Resuscitation was the same as in series 1. RESULTS The blast created bilateral parenchymal contusions (R > L), hemo/pneumothorax and progressive cardiopulmonary distress. In Series 1, there were 3/20 deaths before randomization, 0/8 deaths after resuscitation with AVP versus 4/9 deaths with NS (p = 0.029). In surviving animals, with AVP versus NS, fluid requirements and peak airway pressures were lower while P/F was higher (all p < 0.05). In Series 2, with uncontrolled hemorrhage, there were 5/15 deaths before randomization. Upon resuscitation with AVP versus NS, survival time and blood loss were both improved, but the differences did not reach statistical significance. CONCLUSIONS After severe chest trauma with controlled hemorrhage, early AVP decreased mortality, reduced fluid requirements and improved pulmonary function. With uncontrolled hemorrhage, early AVP did not increase the risk for bleeding.
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Earle SA, Proctor KG, Patel MB, Majetschak M. Ubiquitin reduces fluid shifts after traumatic brain injury. Surgery 2005; 138:431-8. [PMID: 16213895 DOI: 10.1016/j.surg.2005.06.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2004] [Revised: 06/22/2005] [Accepted: 06/24/2005] [Indexed: 12/26/2022]
Abstract
BACKGROUND Ubiquitin has well-described intracellular properties. Recent data also suggest pleiotropic effects of extracellular ubiquitin, including induction of apoptosis, regulation of immune functions, and therapeutic potential during fluid resuscitation from severe trauma. However, the actions of exogenous ubiquitin after traumatic brain injury (TBI) are unknown. METHODS Series 1: Thirty-five minutes after TBI and hemorrhage, 1.5 mg ubiquitin/kg (n = 5) or albumin (n = 5) intravenous was followed by fluid resuscitation to maintain mean arterial and cerebral perfusion pressure. Series 2: Ubiquitin (n = 5) or vehicle (n = 6) was administered after TBI only. Ubiquitin was measured with enzyme-linked immunosorbent assay in serum, urine (series 1), and cerebrospinal fluid (series 2) for 300 minutes. RESULTS Series 1: After intravenous bolus, serum ubiquitin peaked at t = 45 minutes with a half-life of 54 minutes. Recovery in urine was 10%. With albumin versus ubiquitin, 85% more resuscitation fluid was required to stabilize systemic and cerebral hemodynamics (P < .05 for t = 150 to 300 minutes), but hematocrit was similar. With albumin there were progressive increases in intracranial pressure, peak inspiratory pressure, and decreases in oxygenation. All were significantly attenuated by ubiquitin (all P < .05 vs albumin). Series 2: Intravenous ubiquitin altered cerebrospinal fluid ubiquitin with an increased time to peak (t = 88 +/- 13 min vs 45 +/- 7 min, P < .05) and area under the concentration-time curve (82 +/- 22 vs 23 +/- 11 microg/min(1)/mL(-1), P < .05). CONCLUSIONS After TBI, intravenous ubiquitin crossed the blood-brain barrier and significantly reduced third spacing of fluid into the brain and lung during resuscitation.
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King DR, Cohn SM, Proctor KG. Resuscitation with a hemoglobin-based oxygen carrier after traumatic brain injury. THE JOURNAL OF TRAUMA 2005; 59:553-60; discussion 560-2. [PMID: 16361895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) remains an exclusionary criterion in nearly every clinical trial involving hemoglobin-based oxygen carriers (HBOCs) for traumatic hemorrhage. Furthermore, most HBOCs are vasoactive, and use of pressors in the setting of hemorrhagic shock is generally contraindicated. The purpose of this investigation was to test the hypothesis that low-volume resuscitation with a vasoactive HBOC (hemoglobin glutamer-200 [bovine], HBOC-301; Oxyglobin, BioPure, Inc., Cambridge, MA) would improve outcomes after severe TBI and hemorrhagic shock. METHODS In Part 1, anesthetized swine received TBI and hemorrhage (30 +/- 2 mL/kg, n = 15). After 30 minutes, lactated Ringer's (LR) solution (n = 5), HBOC (n = 5), or 10 mL/kg of LR + HBOC (n = 5) was titrated to restore systolic blood pressure to > or = 100 mm Hg and heart rate (HR) to < or = 100 beats/min. After 60 minutes, fluid was given to maintain mean arterial pressure (MAP) at > or = 70 mm Hg and heterologous whole blood (red blood cells [RBCs], 10 mL/kg) was transfused for hemoglobin at < or = 5 g/dL. After 90 minutes, mannitol (MAN, 1 g/kg) was given for intracranial pressure > or = 20 mm Hg, LR solution was given to maintain cerebral perfusion pressure at > or = 70 mm Hg, and RBCs were given for hemoglobin of < or = 5 g/dL. In Part 2, after similar TBI and resuscitation with either LR + MAN + RBCs (n = 3) or HBOC alone (n = 3), animals underwent attempted weaning, extubation, and monitoring for 72 hours. RESULTS In Part 1, relative to resuscitation with LR + MAN + RBCs, LR + HBOC attenuated intracranial pressure (12 +/- 1 mm Hg vs. 33 +/- 6 mm Hg), improved cerebral perfusion pressure in the initial 4 hours (89 +/- 6 mm Hg vs. 60 +/- 3 mm Hg), and improved brain tissue PO2 (34.2 +/- 3.6 mm Hg vs. 16.1 +/- 1.6 mm Hg; all p < 0.05). Cerebrovascular reactivity and intracranial compliance were improved with LR + HBOC (p < 0.05) and fluid requirements were reduced (30 +/- 12 vs. 280 +/- 40 mL/kg; p < 0.05). Lactate and base excess corrected faster with LR + HBOC despite a 40% reduction in cardiac index. With HBOC alone and LR + HBOC, MAP and HR rapidly corrected and remained normal during observation; however, with HBOC alone, lactate clearance was slower and systemic oxygen extraction was transiently increased. In Part 2, resuscitation with HBOC alone allowed all animals to wean and extubate, whereas none in the LR + MAN + RBCs group was able to wean and extubate. At 72 hours, no HBOC animal had detectable neurologic deficits and all had normal hemodynamics. CONCLUSION The use of HBOC-301 supplemented by a crystalloid bolus was clearly superior to the standard of care (LR + MAN + RBCs) after TBI. This may represent a new indication for HBOCs. Use of HBOC eliminated the need for RBC transfusions and mannitol. The inherent vasopressor effect of HBOCs, especially when used alone, may misguide initial resuscitation, leading to transient poor global tissue perfusion despite restoration of MAP and HR. This suggests that MAP and HR are inadequate endpoints with HBOC resuscitation. HBOC use alone after TBI permitted early extubation and excellent 72-hour outcomes.
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Majetschak M, King DR, Krehmeier U, Busby LT, Thome C, Vajkoczy S, Proctor KG. Ubiquitin immunoreactivity in cerebrospinal fluid after traumatic brain injury: Clinical and experimental findings. Crit Care Med 2005; 33:1589-94. [PMID: 16003067 DOI: 10.1097/01.ccm.0000169883.41245.23] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Recent data indicate that ubiquitin is increased in serum after trauma and might regulate immune functions. Its cellular source is unknown. Because there have been no previous studies after traumatic brain injury (TBI), we determined whether ubiquitin immunoreactivity is increased in cerebrospinal fluid (CSF) after TBI. DESIGN AND SETTING Prospective observational study of patients, with a subsequent interventional study of animals. SUBJECTS The subjects were 14 patients with TBI, five patients with nontraumatic subarachnoid hemorrhage, ten nonneurologic controls, and seven cross-bred swine. INTERVENTIONS Standardized TBI. MEASUREMENTS AND MAIN RESULTS Ubiquitin immunoreactivity was analyzed by enzyme-linked immunosorbent assay and immunoblotting. Hemolysis was assessed spectrophotometrically. CSF ubiquitin levels (mean +/- sd) were 19 +/- 3 ng/mL in nonneurologic control patients, 81 +/- 48 ng/mL at 7 +/- 2 hrs after TBI (p = .002), and at the end of operation in patients with nontraumatic subarachnoid hemorrhage they were 104 +/- 68 ng/mL (p = .001). CSF and serum ubiquitin were measured for 7 days in six patients with TBI. In survivors (n = 3), CSF ubiquitin levels progressively recovered, whereas in nonsurvivors (n = 3), the levels increased until death. There was no difference in serum ubiquitin levels between survivors/nonsurvivors and there was no correlation between serum and CSF ubiquitin levels. In swine, CSF ubiquitin levels peaked at 8- to 30-fold higher than baseline at 60 min post-TBI and then declined with a half-life of 1.3 hrs. In CSF with hemolysis, peak ubiquitin levels were five-fold higher than without hemolysis (p < .05). Ubiquitin and hemoglobin correlations in CSF and after in vitro lysis of erythrocytes suggested that erythrolysis could account for no more than 23 +/- 16% of the CSF ubiquitin. CONCLUSIONS CSF ubiquitin levels are increased more than four-fold in patients after TBI and nontraumatic subarachnoid hemorrhage. Peak CSF ubiquitin measurements in patients with TBI probably underestimated the actual peak, on the basis of data from the animal model. The progressive rise in CSF ubiquitin in patients with TBI who died suggests that lack of clearance could reflect lethal progression to irreversible brain damage. Erythrolysis is one potential source of CSF ubiquitin.
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Crookes BA, Cohn SM, Bloch S, Amortegui J, Manning R, Li P, Proctor MS, Hallal A, Blackbourne LH, Benjamin R, Soffer D, Habib F, Schulman CI, Duncan R, Proctor KG. Can near-infrared spectroscopy identify the severity of shock in trauma patients? THE JOURNAL OF TRAUMA 2005; 58:806-13; discussion 813-6. [PMID: 15824660 DOI: 10.1097/01.ta.0000158269.68409.1c] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Our recent experimental study showed that peripheral muscle tissue oxygen saturation (StO2), determined noninvasively by near-infrared spectroscopy (NIRS), was more reliable than systemic hemodynamics or invasive oxygenation variables as an index of traumatic shock. The purpose of this study was to establish the normal range of thenar muscle StO2 in humans and the relationship between shock state and StO2 in trauma patients. METHODS This was a prospective, nonrandomized, observational, descriptive study in normal human volunteers (n = 707) and patients admitted to the resuscitation area of our Level I trauma center (n = 150). To establish a normal StO2 range, an NIRS probe was applied to the thenar eminence of volunteers (normals). Subsequently, in a group of trauma patients, an NIRS probe was applied to the thenar eminence and data were collected and stored for offline analysis. StO2 monitoring was performed continuously and noninvasively, and values were recorded at 2-minute intervals. Five moribund trauma patients were excluded. Members of our trauma faculty, blinded to StO2 values, classified each patient into one of four groups (no shock, mild shock, moderate shock, and severe shock) using conventional physiologic parameters. RESULTS Mean +/- SD thenar StO2 values for each group were as follows: normals, 87 +/- 6% (n = 707); no shock, 83 +/- 10% (n = 85); mild shock, 83 +/- 10% (n = 19); moderate shock, 80 +/- 12% (n = 14); and severe shock, 45 +/- 26% (n = 14). The thenar StO2 values clearly discriminated the normals or no shock patients and the patients with severe shock (p < 0.05). CONCLUSION Decreased thenar muscle tissue oxygen saturation reflects the presence of severe hypoperfusion and near-infrared spectroscopy may be a novel method for rapidly and noninvasively assessing changes in tissue dysoxia.
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King DR, Cohn SM, Proctor KG. Modified rapid deployment hemostat bandage terminates bleeding in coagulopathic patients with severe visceral injuries. ACTA ACUST UNITED AC 2005; 57:756-9. [PMID: 15514529 DOI: 10.1097/01.ta.0000147501.64610.afs] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We recently reported that a new dressing, the Modified Rapid Deployment Hemostat (MRDH) controlled bleeding in hypothermic coagulopathic swine after traumatic liver avulsion. The purpose of this study was to evaluate the MRDH in coagulopathic trauma patients undergoing abbreviated laparotomy. METHODS A prospective, observational clinical trial of the MRDH dressing was performed at our Level One Trauma Center in patients with high-grade visceral injuries with coagulopathy who failed conventional therapy and required packing. Attending surgeons graded the injury and the adequacy of hemostasis following application of the dressing. Patients were followed until discharge or death. RESULTS Ten patients were enrolled: nine severe hepatic injuries, and one major abdominal vascular injury. All patients were hypothermic, acidotic, and clinically coagulopathic. Intraoperative hemostasis was immediately obtained after MRDH placement in all cases except one. There was one death. CONCLUSION The Modified Rapid Deployment Hemostat terminates bleeding from severe visceral injuries in coagulopathic patients undergoing abbreviated laparotomy.
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Crookes BA, Cohn SM, Bonet H, Burton EA, Nelson J, Majetschak M, Varon AJ, Linden JM, Proctor KG. Building a Better Fluid for Emergency Resuscitation of Traumatic Brain Injury. ACTA ACUST UNITED AC 2004; 57:547-54. [PMID: 15454801 DOI: 10.1097/01.ta.0000135162.85859.4c] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Hextend (HEX) is a colloid solution that is FDA-approved for volume expansion during surgery. ATL-146e is a novel adenosine A2A receptor agonist that has anti-inflammatory, neuroprotective, and coronary vasodilator properties. Three series of experiments were designed to evaluate the therapeutic potential of HEX+/-ATL-146e for emergency resuscitation from traumatic brain injury (TBI) + hemorrhagic hypotension. METHODS In the first two studies in vivo, anesthetized, ventilated pigs (30-45 kg) received a fluid percussion TBI, 45% arterial hemorrhage, and 30 minutes shock period. In Series 1, resuscitation consisted of unlimited crystalloid (n = 8) or HEX (n = 8) to correct systolic arterial pressure >100 mm Hg and heart rate <100 bpm for the first 60 minutes ("emergency phase"), and then maintain cerebral perfusion pressure (CPP) > 70 mm Hg for 60-240 minutes. In Series 2 (n = 31), resuscitation consisted of a 1 L bolus of HEX + ATL-146e (10 ng/kg/min, n = 10) or HEX +placebo (n = 10) followed by crystalloid to the same endpoints. In Series 3 in vivo, the hemodynamic response evoked by 0, 10, 50, or 100 ng/kg/min ATL-146e was measured before or 60 minutes after HEX resuscitation from 45% hemorrhage. RESULTS Following TBI+hemorrhage, there were 4/22 deaths in series 1 and 11/31 deaths in series 2. In those alive at 30 minutes, mean arterial pressure, cardiac index, mixed venous O2 saturation, and cerebral venous O2 saturation were all reduced by 40-60%, while heart rate and lactate were increased 2-5 fold. With no resuscitation (n = 2), there was minimal hemodynamic compensation and progressive acidosis. Upon resuscitation, these values corrected but intracranial pressure progressively rose from <5 mm Hg to 15-20 mm Hg. Series 1: With HEX (n = 8) versus crystalloid (n = 8), CPP was less labile, acid/base was maintained, and the fluid requirement was reduced by 60% (all p < 0.05) Series 2: With ATL-146e (n = 10) versus placebo (n = 10), stroke volume and cardiac output were improved by 40-60%, and the fluid requirement was reduced by 30% (all p < 0.05). Series 3: ATL-146e caused a dose-related increase (p < 0.05) in stroke volume after, but not before, hemorrhage. The effects on pre-load, afterload, and heart rate were similar before and after hemorrhage. CONCLUSIONS HEX alone is a safe and efficacious low volume alternative to initial crystalloid resuscitation after TBI. An adenosine A2A agonist combined with 1 L of HEX safely and effectively counteracted a decrease in cardiac performance noted after TBI+hemorrhage without causing hypotension or bradycardia.
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King DR, Cohn SM, Proctor KG. Changes in intracranial pressure, coagulation, and neurologic outcome after resuscitation from experimental traumatic brain injury with hetastarch. Surgery 2004; 136:355-63. [PMID: 15300202 DOI: 10.1016/j.surg.2004.05.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND In a model of traumatic brain injury (TBI), 2 protocols compared changes in intracranial pressure (ICP), coagulation, and neurologic outcome after intravenous fluid (IVF) resuscitation with either Hextend (HEX, 6% hetastarch in lactated electrolyte injection) or standard of care, crystalloid plus mannitol (MAN). METHODS In the nonsurvivor protocol, swine (n = 28) received a fluid percussion TBI and hemorrhage (27 +/- 3 mL/kg). At 30 minutes, resuscitation began with lactated Ringer's (LR) or HEX. After 60 minutes, MAN (1 g/kg) or placebo was given plus supplemental IVF to maintain cerebral perfusion pressure (CPP) > or = 70 mm Hg for 240 minutes. Swine in the survivor group (n = 15) also underwent TBI and hemorrhage, and resuscitation with HEX was compared to that of normal saline (NS)+MAN. Neurologic outcome and coagulation were evaluated for 72 hours. RESULTS In the nonsurvivor protocol, HEX, LR+MAN, and HEX+MAN attenuated the time-related rise of ICP and prevented ICP >20 mm Hg versus LR alone (P < .05). HEX alone maintained CPP (relative to baseline) and decreased total IVF by 50% versus LR +/- MAN (P < .05). MAN had no additive effect with HEX. Coagulation, measured by thromboelastograph reaction time (R), was 11 +/- 1 and 9 +/- 1 minutes at baseline and after TBI (before randomization). At 240 minutes after HEX or LR+MAN, R was 6 +/- 1 or 7 +/- 2 minutes, which indicates a hypercoagulable state, but there was no difference between treatments. In the survivor protocol, ICP and CPP were similar with NS+MAN versus HEX, but IVF requirement was 161 +/- 20 versus 28 +/- 3 mL/kg (P < .05). Motor scores were higher on days 2 and 3 with HEX (P < .05). At 72 hours, R was 28 +/- 14 versus 26 +/- 6 minutes with NS+MAN versus HEX, which indicates a hypocoagulable state, but there was no difference between treatments. CONCLUSIONS Hextend as the sole resuscitation fluid after severe TBI reduces fluid requirement, obviates the need for mannitol, improves neurologic outcome, and has no adverse effect on the coagulation profile relative to the crystalloid plus mannitol standard of care.
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Crookes BA, Cohn SM, Burton EA, Nelson J, Proctor KG. Noninvasive muscle oxygenation to guide fluid resuscitation after traumatic shock. Surgery 2004; 135:662-70. [PMID: 15179373 DOI: 10.1016/j.surg.2003.11.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Three different protocols tested the hypothesis that hind limb muscle tissue O(2) saturation (StO(2)), measured noninvasively with near-infrared spectroscopy (NIRS), is as reliable as invasive systemic oxygenation indices to guide fluid resuscitation. METHODS In series 1, swine (n=30) were hemorrhaged, then received either no fluid, a fixed volume of colloid (15 mL/kg), or shed blood plus lactated Ringer's (LR) titrated to MAP >60 mm Hg. In series 2, swine (n=16) received a penetrating femur injury, a 47% to 55% hemorrhage to determine a median lethal dose (LD(50)) then shed blood plus LR titrated to MAP >60 mm Hg. In series 3, swine (n=5) received the femur injury plus LD(50) hemorrhage, and were resuscitated with LR titrated to StO(2) >50%. RESULTS In series 1, StO(2) tracked mixed venous O(2) saturation (SvO(2)), but discriminated between 3 survivor groups better than SvO(2), arterial lactate, or arterial base excess. In series 2, StO(2) tracked SvO(2) but discriminated between 2 survivor groups better than SvO(2), arterial lactate, or arterial base excess. In series 3, animals survived to extubation when resuscitated to an StO(2) target. CONCLUSIONS Noninvasive muscle StO(2) determined by NIRS was more reliable than invasive oxygenation variables as an index of shock. Because muscle StO(2) can be easily monitored in emergency situations, it may represent an improved method to gauge the severity of shock or the adequacy of fluid resuscitation after trauma.
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Majetschak M, Cohn SM, Obertacke U, Proctor KG. Therapeutic potential of exogenous ubiquitin during resuscitation from severe trauma. ACTA ACUST UNITED AC 2004; 56:991-9; discussion 999-1000. [PMID: 15179237 DOI: 10.1097/01.ta.0000127770.29009.5a] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent studies suggest that extracellular ubiquitin could have a physiologic role in immunodepression in sepsis and trauma. The therapeutic potential of exogenous ubiquitin after trauma has not been examined. To fill this gap, we designed a series of experiments in a clinically relevant trauma model. METHODS Forty minutes after femur fractures and hemorrhage, swine received 1.3 mg of ubiquitin per kilogram or bovine serum albumin intravenously followed by fluid resuscitation to maintain systemic hemodynamics. Leukocyte function and the immunomodulatory capacity of serum were assessed measuring endotoxin-evoked tumor necrosis factor-alpha (TNF alpha) production ex vivo. TNF alpha and ubiquitin were quantified with enzyme-linked immunosorbent assay. RESULTS Intravenous ubiquitin had no significant hemodynamic effect in normal animals. After injury, ubiquitin significantly reduced fluid requirements by at least 60% (p < 0.05). The injury was associated with transient immunodepression, as reflected by reduced endotoxin-evoked TNF alpha production by 40% to 50%. With ubiquitin, this response remained depressed for 100 to 160 minutes (p < 0.05), but fully recovered to baseline with albumin. CONCLUSION Ubiquitin is apparently safe and effective for reducing fluid requirements as a measure of diffuse capillary leak. This immunomodulatory property suggests a new therapeutic approach after injury in particular, and for infectious and noninfectious inflammation in general.
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Majetschak M, Cohn SM, Nelson JA, Burton EH, Obertacke U, Proctor KG. Effects of exogenous ubiquitin in lethal endotoxemia. Surgery 2004; 135:536-43. [PMID: 15118591 DOI: 10.1016/j.surg.2003.09.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent data indicated a potential role for extracellular ubiquitin in hematopoiesis and inflammation. The biological significance and therapeutic potential of these findings in vivo are unknown. Based on its in vitro abilities to inhibit endotoxin-stimulated tumor necrosis factor alpha (TNFalpha) production, we hypothesized that exogenous ubiquitin has salutary effects on sequelae caused by endotoxin in vivo. METHODS Anesthetized and mechanically ventilated swine were infused with endotoxin for 3 hours. Ubiquitin was administered intravenously either 15 minutes before or 45 minutes after the endotoxin infusion was started. Albumin was administered to a control group. An additional control group received only ubiquitin. Ex vivo endotoxin evoked TNFalpha production was measured using a whole blood assay. Ubiquitin and TNFalpha concentrations were determined by enzyme-linked immunosorbent assay. RESULTS Ubiquitin reduced mortality (P <.05), prevented development of pulmonary failure (P <.05), reduced fluid requirements (P <.05), and diminished erythema and edema formation. Ubiquitin pretreatment was more effective than treatment 45 minutes after an endotoxin infusion was started. In vivo ubiquitin administration alone inhibited ex vivo endotoxin-evoked TNFalpha secretion, but had no effect on TNFalpha serum levels after endotoxin infusion. CONCLUSION In vivo ubiquitin administration has salutary actions during lethal endotoxemia and inhibits ex vivo whole blood TNFalpha production upon endotoxin stimulation. The clinical appearance after ubiquitin treatment in endotoxemia indicates the endothelium as another potential target cell population for interactions with ubiquitin. A novel therapeutic approach to a broad variety of diseases, in which endotoxin triggers immune activation, is suggested.
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Malhotra AK, Schweitzer JB, Fox JL, Fabian TC, Proctor KG. Cerebral Perfusion Pressure Elevation with Oxygen-Carrying Pressor after Traumatic Brain Injury and Hypotension in Swine. ACTA ACUST UNITED AC 2004; 56:1049-57. [PMID: 15179245 DOI: 10.1097/01.ta.0000127765.75643.66] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previously, we had shown that elevation of cerebral perfusion pressure, using pressors, improved short-term outcomes after traumatic brain injury and hemorrhagic shock in swine. The current study evaluates outcomes after resuscitation with diaspirin cross-linked hemoglobin (DCLHb)--a hemoglobin-based oxygen carrier with pressor activity--in the same swine model of traumatic brain injury and hemorrhagic shock. METHODS Anesthetized and ventilated swine received traumatic brain injury via cortical fluid percussion (6-8 atm) followed by 45% blood volume hemorrhage. One hour later, animals were randomized to either a control group (SAL) resuscitated with normal saline equal to three times shed blood volume or to one of two experimental groups resuscitated with DCLHb. The two experimental groups consisted of a low-dose group, resuscitated with 250 mL of DCLHb (Hb1), and a high-dose group, resuscitated with 500 mL of DCLHb (Hb2). Animals were observed for 210 minutes postresuscitation. Outcomes evaluated were cerebral oxygenation by measuring partial pressure and saturation of oxygen in cerebrovenous blood; cerebral function by evaluating the preservation and magnitude of cerebrovascular carbon dioxide reactivity; and brain structural damage by semiquantitatively assessing beta amyloid precursor protein positive axons. RESULTS Postresuscitation, cerebral perfusion pressure was higher in the DCLHb groups (p < 0.05, Hb1 and Hb2 vs. SAL), and intracranial pressure was lower in the Hb2 group (p < 0.05 vs. SAL). Cerebrovenous oxygen level was similar in all groups (p > 0.05). At baseline, 5% carbon dioxide evoked a 16 +/- 1% increase in cerebrovenous oxygen saturation, indicating vasodilatation. At 210 minutes, this response was nearly absent in SAL (4 +/- 4%) (p < 0.05 vs. baseline) and Hb1 (1 +/- 5%), but was partially preserved in Hb2 (9 +/- 5%). There was no intergroup difference in beta amyloid precursor protein positive axons. Five of 20 SAL and 0 of 13 DCLHb animals developed brain death (flat electroencephalogram) (p = 0.05, SAL vs. DCLHb). Postresuscitation, DCLHb animals maintained higher mean pulmonary arterial pressure (28 +/- 1 mm Hg, SAL; 42 +/- 1 mm Hg, Hb1; 45 +/- 1 mm Hg, Hb2) (p < 0.05, Hb1 and Hb2 vs. SAL) and lower cardiac output (3.9 +/- 1.6 L/min, SAL; 2.6 +/- 0.1 L/min, Hb1; 2.7 +/- 0.1 L/min, Hb2) (p < 0.05, Hb1 and Hb2 vs. SAL). Three Hb2 animals died as a result of cardiac failure, and one SAL animal died as a result of irreversible shock. CONCLUSION In this swine model of traumatic brain injury and hemorrhagic shock, resuscitation with DCLHb maintained a higher cerebral perfusion pressure. Low-dose DCLHb (minimal increase in oxygen carriage) failed to significantly improve short-term outcome. With high-dose DCLHb (significant improvement in oxygen carriage), intracranial pressure was lower and cerebrovascular carbon dioxide reactivity was partially preserved; however, this was at the cost of poorer cardiac performance secondary to high afterload.
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Varela JE, Cohn SM, Diaz I, Giannotti GD, Proctor KG. Splanchnic Perfusion During Delayed, Hypotensive, or Aggressive Fluid Resuscitation From Uncontrolled Hemorrhage. Shock 2003; 20:476-80. [PMID: 14560114 DOI: 10.1097/01.shk.0000094036.09886.9b] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to determine the effect of three different fluid resuscitation strategies on splanchnic perfusion in a clinically relevant model of uncontrolled hemorrhage after liver trauma. Anesthetized swine were instrumented with a gastric near-infrared spectroscopy probe (GStO2), a jejunal tonometer (PrCO2), a portal vein catheter (SpvO2, lactate), and an ultrasonic blood flow probe on the superior mesenteric artery. The liver was lacerated to produce uncontrolled hemorrhage and a shock state characterized by a 40-60% decrease in cardiac output and a decrease in mean arterial pressure (MAP) to 42 +/- 1 mmHg. Animals were randomly assigned to either delayed resuscitation (n = 6); hypotensive resuscitation with lactated Ringer's infusion to MAP = 60 mmHg (n = 6); or aggressive resuscitation with LR to MAP >/= 75 mmHg (n = 6). For the remainder of the protocol, the treatment was identical. The data showed that blood loss (47 +/- 7 and 45 +/- 10 mL/kg) and total fluid requirements (118 +/- 73 and 171 +/- 85 mL/kg) were similar with either hypotensive or aggressive resuscitation. In contrast, with delayed resuscitation, both values were lower (27 +/- 2 mL/kg and 87 +/- 33 mL/kg, both P < 0.05). Despite aggressive resuscitation, SpvO2 and GstO2 were about 10% lower (both P < 0.05 within group) and PrCO2 was about 20 mmHg higher (P < 0.05 within group) than the corresponding values in the other two groups. Thus, delayed resuscitation minimized the blood loss but did not restore tissue oxygenation, whereas aggressive resuscitation was associated with maximal blood loss and splanchnic hypoperfusion. For this reason, it is reasonable to conclude that hypotensive resuscitation might be an effective strategy to maintain splanchnic perfusion after blunt abdominal trauma and uncontrolled hemorrhage.
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Malhotra AK, Schweitzer JB, Fox JL, Fabian TC, Proctor KG. Cerebral Perfusion Pressure Directed Therapy following Traumatic Brain Injury and Hypotension in Swine. J Neurotrauma 2003; 20:827-39. [PMID: 14577861 DOI: 10.1089/089771503322385764] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is a paucity of studies, clinical and experimental, attesting to the benefit of cerebral perfusion pressure (CPP) directed pressor therapy following traumatic brain injury (TBI). The current study evaluates this therapy in a swine model of TBI and hypotension. Forty-five anesthetized and ventilated swine received TBI followed by a 45% blood volume bleed. After 1 h, all animals were resuscitated with 0.9% sodium chloride equal to three times the shed blood volume. The experimental group (PHE) received phenylephrine to maintain CPP > 80 mm Hg; the control group (SAL) did not. Outcomes in the first phase (n = 33) of the study were as follows: cerebro-venous oxygen saturation (S(cv)O(2)), cerebro-vascular carbon dioxide reactivity (DeltaS(cv)O(2)), and brain structural damage (beta-amyloid precursor protein [betaAPP] immunoreactivity). In the second phase (n = 12) of the study, extravascular blood free water (EVBFW) was measured in the brain and lung. After resuscitation, intracranial and mean arterial pressures were >15 and >80 mm Hg, respectively, in both groups. CPP declined to 64 +/- 5 mm Hg in the SAL group, despite fluid supplements. CPP was maintained at >80 mm Hg with pressors in the PHE group. PHE animals maintained better S(cv)O(2) (p < 0.05 at 180, 210, 240, 270, and 300 min post-TBI). At baseline, 5% CO(2) evoked a 16 +/- 4% increase in S(cv)O(2), indicating cerebral vasodilatation and luxury perfusion. By 240 min, this response was absent in SAL animals and preserved in PHE animals (p < 0.05). Brain EVBFW was higher in SAL animals; however, lung EVBFW was higher in PHE animals. There was no difference in betaAPP immunoreactivity between the SAL and PHE groups (p > 0.05). In this swine model of TBI and hypotension, CPP directed pressor therapy improved brain oxygenation and maintained cerebro-vascular CO(2) reactivity. Brain edema was lower, but lung edema was greater, suggesting a higher propensity for pulmonary complications.
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Jewelewicz DD, Cohn SM, Crookes BA, Proctor KG. Modified rapid deployment hemostat bandage reduces blood loss and mortality in coagulopathic pigs with severe liver injury. THE JOURNAL OF TRAUMA 2003; 55:275-80; discussion 280-1. [PMID: 12913637 DOI: 10.1097/01.ta.0000079375.69610.89] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemostasis can be difficult to achieve after blunt abdominal trauma, especially if the patient is coagulopathic. The U.S. Food and Drug Administration has recently approved a hemostatic dressing for treating bleeding after extremity trauma (RDH bandage; Marine Polymer Technologies, Cambridge, MA). It has not been evaluated for internal bleeding after trauma. We redesigned this dressing for internal use, and then tested whether this modified bandage (Miami-modified Rapid Deployment Hemostat) could achieve hemostasis when used as an adjunct to standard laparotomy pad packing in a pig model of severe liver injury with coagulopathy. METHODS Anesthetized swine (35-45 kg) received an isovolemic 45% blood volume replacement with refrigerated Hextend (6% hetastarch). Core body temperature was maintained at 33-34 degrees C with intra-abdominal ice packs. A coagulopathic condition was documented by thromboelastography. At this point a severe liver injury was induced by the avulsion of the left lateral hepatic lobe, then the pigs were randomized to treatment with either standard abdominal packing (control) or packing plus Miami-modified Rapid Deployment Hemostat. Two series of experiments were conducted. In series one (n = 14), the abdomen was closed and the animals were observed with no resuscitation. After one hour, the abdomen was opened, the packing was removed and the presence of bleeding was noted. In series two (n = 10), the abdomen was closed and the animal resuscitated with one unit of blood plus as much lactated Ringers intravenous fluid (IVF) as required to maintain a mean arterial pressure (MAP) > 70 mm Hg. After one hour, the packing was removed, the abdomen closed, and data were collected for an additional two hours. RESULTS Series one: 6/7 animals in the control group had continued bleeding at one hour; 1/7 animals in the treatment group had active bleeding (p = 0.0291). Series two: With control vs. Miami-modified Rapid Deployment Hemostat, the three-hour survival was zero vs. 80% (p = 0.0476). The total blood loss was 1.2 +/- 0.1 vs. 0.3 +/- 0.1 mL/kg/min (p = 0.001) and the IVF requirement was 1.6 +/- 0.3 vs. 0.6 +/- 0.3 mL/kg/min (p = 0.026). CONCLUSIONS The Miami-modified Rapid Deployment Hemostat bandage significantly reduced mortality, blood loss, and fluid requirements when used as an adjunct to standard abdominal packing following severe liver injury in coagulopathic pigs [corrected].
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Kelly ME, Miller PR, Greenhaw JJ, Fabian TC, Proctor KG. Novel resuscitation strategy for pulmonary contusion after severe chest trauma. THE JOURNAL OF TRAUMA 2003; 55:94-105. [PMID: 12855887 DOI: 10.1097/01.ta.0000029042.37577.a6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Adenosine A2a receptor stimulation can increase coronary perfusion and also reduce leukocyte-mediated inflammatory responses in some conditions. Hextend is a novel colloid solution that may have antioxidant properties. All these actions might be beneficial after severe chest trauma, but have never been investigated. To fill these gaps, this study evaluated the therapeutic potential of a novel adenosine A2a agonist during fluid resuscitation from severe chest trauma with either standard-of-care crystalloid or Hextend. METHODS Anesthetized, ventilated swine received unilateral, blunt trauma to the right chest via captive bolt gun, followed by a 10- to 12-mL/kg arterial hemorrhage. After 25 minutes of shock, ATL-146e was started (10 ng/kg/min intravenously for 180 minutes). After an additional 5 minutes, the minimum amount of either colloid (Hextend, 5% hetastarch in lactate-buffered, balanced electrolyte solution) or crystalloid (lactated Ringer's [LR] solution) was administered to maintain mean arterial pressure > 70 mm Hg and heart rate < 100 beats/min and to correct lactate for 180 minutes postinjury. Cardiopulmonary function was monitored and serial bronchoalveolar lavage samples were analyzed for protein, leukocyte infiltration, and expression of cyclooxygenase (COX)-1 and COX-2 isozymes as markers of the inflammatory cascade. RESULTS Fluid requirements were reduced by half with Hextend compared with LR (p < 0.05). ATL-146e in either Hextend or LR transiently increased cardiac output, cardiac contractility, and systemic oxygen delivery (all p < 0.05). Pao(2)/Fio(2) ratio was 50 to 100 higher and bronchoalveolar lavage leukocytes were reduced by half with Hextend versus LR (both p < 0.05), but there was no added effect of ATL-146e. COX-1 expression was induced in macrophages (Mphis), whereas COX-2 was induced in neutrophils. Neither Hextend nor ATL-146e reduced COX expression. CONCLUSION Hextend reduced the volume for initial resuscitation, which may offer logistical advantages in prehospital field conditions or whenever there is limited medical resources or prolonged transport times; ATL-146e improved early cardiac performance without causing hypotension or bradycardia; when administered 25 to 30 minutes after injury, neither Hextend nor ATL-146e altered inflammatory changes in pulmonary Mphis or infiltrating PMNs; and further studies are needed to determine whether these short-term benefits correlate with long-term outcome.
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Cohn SM, Crookes BA, Proctor KG. Near-infrared spectroscopy in resuscitation. THE JOURNAL OF TRAUMA 2003; 54:S199-202. [PMID: 12768125 DOI: 10.1097/01.ta.0000047225.53051.7c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
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