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Polynitroxylated-pegylated hemoglobin attenuates fluid requirements and brain edema in combined traumatic brain injury plus hemorrhagic shock in mice. J Cereb Blood Flow Metab 2013; 33:1457-64. [PMID: 23801241 PMCID: PMC3764379 DOI: 10.1038/jcbfm.2013.104] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 04/18/2013] [Accepted: 05/28/2013] [Indexed: 11/08/2022]
Abstract
UNLABELLED Polynitroxylated-pegylated hemoglobin (PNPH), a bovine hemoglobin decorated with nitroxide and polyethylene glycol moieties, showed neuroprotection vs. lactated Ringer's (LR) in experimental traumatic brain injury plus hemorrhagic shock (TBI+HS). HYPOTHESIS Resuscitation with PNPH will reduce intracranial pressure (ICP) and brain edema and improve cerebral perfusion pressure (CPP) vs. LR in experimental TBI+HS. C57/BL6 mice (n=20) underwent controlled cortical impact followed by severe HS to mean arterial pressure (MAP) of 25 to 27 mm Hg for 35 minutes. Mice (n=10/group) were then resuscitated with a 20 mL/kg bolus of 4% PNPH or LR followed by 10 mL/kg boluses targeting MAP>70 mm Hg for 90 minutes. Shed blood was then reinfused. Intracranial pressure was monitored. Mice were killed and %brain water (%BW) was measured (wet/dry weight). Mice resuscitated with PNPH vs. LR required less fluid (26.0±0.0 vs. 167.0±10.7 mL/kg, P<0.001) and had a higher MAP (79.4±0.40 vs. 59.7±0.83 mm Hg, P<0.001). The PNPH-treated mice required only 20 mL/kg while LR-resuscitated mice required multiple boluses. The PNPH-treated mice had a lower peak ICP (14.5±0.97 vs. 19.7±1.12 mm Hg, P=0.002), higher CPP during resuscitation (69.2±0.46 vs. 45.5±0.68 mm Hg, P<0.001), and lower %BW vs. LR (80.3±0.12 vs. 80.9±0.12%, P=0.003). After TBI+HS, resuscitation with PNPH lowers fluid requirements, improves ICP and CPP, and reduces brain edema vs. LR, supporting its development.
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Taguchi K, Maruyama T, Iwao Y, Sakai H, Kobayashi K, Horinouchi H, Tsuchida E, Kai T, Otagiri M. Pharmacokinetics of single and repeated injection of hemoglobin-vesicles in hemorrhagic shock rat model. J Control Release 2009; 136:232-9. [DOI: 10.1016/j.jconrel.2009.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Revised: 02/10/2009] [Accepted: 02/10/2009] [Indexed: 10/21/2022]
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Abstract
After decades of research activities and product improvements in the field of artificial oxygen carriers based on either haemoglobin modifications or perfluorocarbon emulsions, these products have reached a critical stage of their development. Varieties of haemoglobin-based oxygen carriers and perfluorocarbon emulsions are under current clinical investigation. Although the clinical availability of artificial oxygen carriers may result in profound changes of fluid resuscitation from haemorrhage, the transfusion of human blood components as an integral part of medical trauma management will not be replaced. However, a rapid and effective restoration of tissue oxygenation by the use of artificial oxygen carriers in the treatment of severe haemorrhage may bridge time delays until stored and cross-matched human packed red cells are available. Whether artificial oxygen carriers could provide additional clinical benefits by sustaining tissue oxygenation even under conditions of a disturbed macro- or microcirculation is the subject of current investigations. Therefore, the application of safe and effective artificial oxygen carriers would not only be restricted to the treatment of severe haemorrhage, but additional therapeutic indications of artificial oxygen carriers in emergency medicine, trauma anaesthesia and other medical specialities would emerge.
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Affiliation(s)
- K F Waschke
- Department of Anaesthesiology and Critical Care Medicine, Faculty of Clinical Medicine Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany.
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Rixen D, Siegel JH. Bench-to-bedside review: oxygen debt and its metabolic correlates as quantifiers of the severity of hemorrhagic and post-traumatic shock. Crit Care 2005; 9:441-53. [PMID: 16277731 PMCID: PMC1297598 DOI: 10.1186/cc3526] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
Evidence is increasing that oxygen debt and its metabolic correlates are important quantifiers of the severity of hemorrhagic and post-traumatic shock and and may serve as useful guides in the treatment of these conditions. The aim of this review is to demonstrate the similarity between experimental oxygen debt in animals and human hemorrhage/post-traumatic conditions, and to examine metabolic oxygen debt correlates, namely base deficit and lactate, as indices of shock severity and adequacy of volume resuscitation. Relevant studies in the medical literature were identified using Medline and Cochrane Library searches. Findings in both experimental animals (dog/pig) and humans suggest that oxygen debt or its metabolic correlates may be more useful quantifiers of hemorrhagic shock than estimates of blood loss, volume replacement, blood pressure, or heart rate. This is evidenced by the oxygen debt/probability of death curves for the animals, and by the consistency of lethal dose (LD)25,50 points for base deficit across all three species. Quantifying human post-traumatic shock based on base deficit and adjusting for Glasgow Coma Scale score, prothrombin time, Injury Severity Score and age is demonstrated to be superior to anatomic injury severity alone or in combination with Trauma and Injury Severity Score. The data examined in this review indicate that estimates of oxygen debt and its metabolic correlates should be included in studies of experimental shock and in the management of patients suffering from hemorrhagic shock.
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Affiliation(s)
- Dieter Rixen
- Department of Trauma/Orthopedic Surgery, University of Witten/Herdecke at the Hospital Merheim, Cologne, Germany
| | - John H Siegel
- Department of Surgery & Department of Cell Biology and Molecular Medicine, New Jersey Medical School, University of Medicine and Dentistry of New Jersey (UMDNJ), Newark, New Jersey, USA
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Sakai H, Masada Y, Horinouchi H, Yamamoto M, Ikeda E, Takeoka S, Kobayashi K, Tsuchida E. Hemoglobin-vesicles suspended in recombinant human serum albumin for resuscitation from hemorrhagic shock in anesthetized rats*. Crit Care Med 2004; 32:539-45. [PMID: 14758176 DOI: 10.1097/01.ccm.0000109774.99665.22] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hemoglobin-vesicle (HbV) has been developed to provide oxygen-carrying ability to plasma expanders. Its ability to restore the systemic condition after hemorrhagic shock was evaluated in anesthetized Wistar rats for 6 hrs after resuscitation. The HbV was suspended in 5 g/dL recombinant human serum albumin (HbV/rHSA) at an Hb concentration of 8.6 g/dL. DESIGN Prospective, randomized, controlled trial. SETTING Department of Surgery, School of Medicine, Keio University. SUBJECTS Forty male Wistar rats. INTERVENTIONS The rats were anesthetized with 1.5% sevoflurane inhalation throughout the experiment. Polyethylene catheters were introduced through the right jugular vein into the right atrium for infusion and into the right common carotid artery for blood withdrawal and mean arterial pressure monitoring. MEASUREMENTS AND MAIN RESULTS Shock was induced by 50% blood withdrawal. The rats showed hypotension (mean arterial pressure = 32 +/- 10 mm Hg) and significant metabolic acidosis and hyperventilation. After 15 mins, they received HbV/rHSA, shed autologous blood (SAB), washed homologous red blood cells (wRBC) suspended in rHSA (wRBC/rHSA, [Hb] = 8.6 g/dL), or rHSA alone. The HbV/rHSA group restored mean arterial pressure to 93 +/- 8 mm Hg at 1 hr, similar to the SAB group (92 +/- 9 mm Hg), which was significantly higher compared with the rHSA (74 +/- 9 mm Hg) and wRBC/rHSA (79 +/- 8 mm Hg) groups. There was no remarkable difference in the blood gas variables between the resuscitated groups; however, two of eight rats in the rHSA group died before 6 hrs. After 6 hrs, the rHSA group showed significant ischemic changes in the right cerebral hemisphere relating to the ligation of the right carotid artery followed by cannulation, whereas the HbV/rHSA, SAB, and wRBC/rHSA groups showed less changes. CONCLUSIONS HbV suspended in recombinant human serum albumin provides restoration from hemorrhagic shock that is comparable with that using shed autologous blood.
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Affiliation(s)
- Hiromi Sakai
- Advanced Research Institute for Science and Engineering, Waseda University, Tokyo, Japan
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van Iterson M, Siegemund M, Burhop K, Ince C. Hemoglobin-based oxygen carrier provides heterogeneous microvascular oxygenation in heart and gut after hemorrhage in pigs. ACTA ACUST UNITED AC 2004; 55:1111-24. [PMID: 14676658 DOI: 10.1097/01.ta.0000101391.58216.dd] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In this study, the hypothesis was tested that resuscitation with hemoglobin-based oxygen carriers (HBOCs) affects the oxygenation of the microcirculation differently between and within organs. To this end, we tested the influence of the volume of an HBOC on the microcirculatory oxygenation of the heart and the gut serosa and mucosa in a porcine model of hemorrhage. METHODS In anesthetized open-chested pigs (n = 24), a controlled hemorrhage (30 mL/kg over 1 hour) was followed by resuscitation with 10, 20, or 30 mL/kg diaspirin-crosslinked hemoglobin (DCLHb) or isovolemic resuscitation with 30 mL/kg of a 6% hydroxyethyl starch solution (HAES). Measurements included systemic and regional hemodynamic and oxygenation parameters. Microvascular oxygen pressures (microPO2) of the epicardium and the serosa and mucosa of the ileum were measured simultaneously by the palladium-porphyrin phosphorescence technique. Measurements were obtained up to 120 minutes after resuscitation. RESULTS After hemorrhage, a low volume of DCLHb restored both cardiac and intestinal microPO2. Resuscitation of gut microPO2 with a low volume of DCLHb was as effective as isovolemic resuscitation with HAES. Higher volumes of DCLHb did not restore cardiac microPO2, as did isovolemic resuscitation with HAES, but increased gut microPO2 to hyperoxic values, dose-dependently. Effects were similar for the serosal and mucosal microPo2. In contrast to a sustained hypertensive effect after resuscitation with DCLHb, effects of DCLHb on regional oxygenation and hemodynamics were transient. CONCLUSION This study showed that a low volume of DCLHb was effective in resuscitation of the microcirculatory oxygenation of the heart and gut back to control levels. Increasing the volume of DCLHb did not cause an additional increase in heart microPO2, but caused hyperoxic microvascular values in the gut to be attained. It is concluded that microcirculatory monitoring in this way elucidates the regional behavior of oxygen transport to the tissue by HBOCs, whereas systemic variables were ineffective in describing their response.
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Affiliation(s)
- Mat van Iterson
- Department of Physiology, Academic Medical Center, University of Amsterdam, The Netherlands
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Sloan EP. The clinical trials of diaspirin cross-linked hemoglobin (DCLHb) in severe traumatic hemorrhagic shock: the tale of two continents. Intensive Care Med 2003; 29:347-9. [PMID: 12710459 DOI: 10.1007/s00134-003-1637-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kerner T, Ahlers O, Veit S, Riou B, Saunders M, Pison U. DCL-Hb for trauma patients with severe hemorrhagic shock: the European "On-Scene" multicenter study. Intensive Care Med 2003; 29:378-85. [PMID: 12541156 DOI: 10.1007/s00134-002-1622-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2002] [Accepted: 11/29/2002] [Indexed: 01/01/2023]
Abstract
OBJECTIVE A major cause of death in patients with severe hemorrhagic shock following trauma is the subsequent occurrence of multiple organ failure due to tissue hypoxia. Early administration of an oxygen carrier may reduce the occurrence of organ failures and improve survival. It may also reduce the need of blood products. DESIGN AND SETTING Prospective multicenter study in a university clinic. PATIENTS 121 patients with severe hemorrhagic shock. INTERVENTIONS Patients were randomly assigned "on-scene" to receive either up to 1000 ml of a 10% diaspirin cross-linked hemoglobin (DCLHb) solution or the study center's standard therapy. MEASUREMENTS AND RESULTS Demographic and physiological characteristics of the two treatment groups at baseline were comparable. Organ failures and survival rates until day 5 and day 28 showed no significant differences. The sponsor therefore terminated this trial prematurely after an interim evaluation of the data indicated no evidence of efficacy to offset concerns raised about the safety of DCLHb. Median volumes of cumulative blood products administered on 1 (1595 vs. 3716 ml) and 7 days (3139 vs. 4746 ml) after admission were lower in the DCLHb group. CONCLUSIONS The early application of an oxygen carrier (DCLHb) to patients with severe hemorrhagic shock following trauma had no significant effect on the occurrence of organ failure or on 5- and 28-day survival in this abbreviated trial. However, early infusion of up to 1000 ml DCLHb reduces the need for blood products without changing morbidity or survival.
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Affiliation(s)
- Thoralf Kerner
- Klinik für Anästhesiologie und Operative Intensivmedizin, Campus Virchow-Klinikum, Charité, Humboldt Universität, Augustenburger Platz 1, 13353 Berlin, Germany
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Asensio JA, Rojo E, Petrone P, Karsidag T, Pardo M, Demiray S, Ricardo Ramos-Kelly J, Ramírez J, Roldán G, Pak-art R, Kuncir E. Síndrome de exanguinación. Factores predictivos e indicativos para la institución de la cirugía de control de daños. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72102-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sakai H, Takeoka S, Wettstein R, Tsai AG, Intaglietta M, Tsuchida E. Systemic and microvascular responses to hemorrhagic shock and resuscitation with Hb vesicles. Am J Physiol Heart Circ Physiol 2002; 283:H1191-9. [PMID: 12181150 DOI: 10.1152/ajpheart.00080.2002] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A phospholipid vesicle encapsulating hemoglobin (Hb vesicle, HbV) has been developed to provide O(2)-carrying capacity to plasma expanders. Its ability to restore systemic and microcirculatory conditions after hemorrhagic shock was evaluated in the dorsal skinfold window preparation of conscious hamsters. The HbV was suspended in 8% human serum albumin (HSA) at Hb concentrations of 3.8 g/dl [HbV(3.8)/HSA] and 7.6 g/dl [HbV(7.6)/HSA]. Shock was induced by 50% blood withdrawal, and mean arterial pressure (MAP) at 40 mmHg was maintained for 1 h by the additional blood withdrawal. The hamsters receiving either HbV(3.8)/HSA or HbV(7.6)/HSA suspensions restored MAP to 93 +/- 14 and 93 +/- 10 mmHg, respectively, similar with those receiving the shed blood (98 +/- 13 mmHg), which were significantly higher by comparison with resuscitation with HSA alone (62 +/- 12 mmHg). Only the HSA group tended to maintain hyperventilation and negative base excess after the resuscitation. Subcutaneous microvascular blood flow reduced to approximately 10-20% of baseline during shock, and reinfusion of shed blood restored blood flow to approximately 60-80% of baseline, an effect primarily due to the sustained constriction of small arteries A(0) (diameter 143 +/- 29 microm). The HbV(3.8)/HSA group had significantly better microvascular blood flow recovery and nonsignificantly better tissue oxygenation than of the HSA group. The recovery of base excess and improved tissue oxygenation appears to be primarily due to the increased oxygen-carrying capacity of HbV fluid resuscitation.
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Affiliation(s)
- Hiromi Sakai
- Advanced Research Institute for Science and Engineering, Waseda University, Tokyo 169-8555, Japan
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Sloan EP, Koenigsberg M, Brunett PH, Bynoe RP, Morris JA, Tinkoff G, Dalsey WC, Ochsner MG. Post hoc mortality analysis of the efficacy trial of diaspirin cross-linked hemoglobin in the treatment of severe traumatic hemorrhagic shock. THE JOURNAL OF TRAUMA 2002; 52:887-95. [PMID: 11988654 DOI: 10.1097/00005373-200205000-00011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The efficacy trial of diaspirin cross-linked hemoglobin (DCLHb) in traumatic hemorrhagic shock demonstrated an unexpected mortality imbalance, prompting a three-step review to better understand the cause of this finding. METHODS Patients were enrolled in this DCLHb hemorrhagic shock study using 28-day mortality as the primary endpoint. Mortality data were primarily analyzed using the TRISS method and a nonblinded clinical review, followed by an independent Pennsylvania Trauma Outcome Study (PTOS)-derived probability of survival analyses. Finally, a trauma expert conducted a blinded clinical review of cases incorrectly predicted by these PTOS analyses. RESULTS More of the DCLHb patients predicted to survive using TRISS actually died than in the control subgroup (24% vs. 3%, p < 0.002). Nonblinded clinical review noted that 72% of the patients who died had prior traumatic arrest, a presenting Glasgow Coma Scale score of 3, or a base deficit > 15 mEq/L. DCLHb patients predicted to survive using PTOS also more often died than did control patients (30% vs. 8%, p < 0.04). Blinded clinical review determined that 94% of the deaths were clinically justified. Both the TRISS and the PTOS models gave an adjusted mortality relative risk of 2.3, similar to the unadjusted risk data. CONCLUSION Mortality analysis in this shock study involved both clinical case reviews and mortality prediction models. Despite the observation that nearly all of the deaths were clinically justified, the TRISS and PTOS models demonstrated excess unpredicted deaths in the DCLHb subgroup. A combined process, using both mortality prediction models and clinical case reviews, is useful in trauma studies that use a mortality endpoint.
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Affiliation(s)
- Edward P Sloan
- Department of Emergency Medicine, University of Illinois at Chicago, 60612, USA.
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12
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Vane LA, Funston JS, Kirschner R, Harper D, Deyo DJ, Traber DL, Traber LL, Kramer GC. Comparison of transfusion with DCLHb or pRBCs for treatment of intraoperative anemia in sheep. J Appl Physiol (1985) 2002; 92:343-53. [PMID: 11744677 DOI: 10.1152/jappl.2002.92.1.343] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Isoflurane-anesthetized sheep were transfused with packed red blood cells (pRBCs) or diaspirin cross-linked hemoglobin (DCLHb) for treatment of intraoperative hemorrhage. A rapid 15-min hemorrhage with lactated Ringer (LR) infusion maintained filling pressure at baseline and reduced blood hemoglobin (Hb) to ~5 g/dl. Sheep received 2 g/kg Hb, DCLHb (n = 6), or pRBCs (n = 7); control group received LR alone (n = 6). After 2 h, anesthesia was discontinued; sheep were monitored in the animal intensive care unit for 48 h. DCLHb expanded blood volume more, but increased total blood Hb less, than pRBCs. Lower Hb and increased methemoglobin resulted in lower arterial oxygen content compared with the pRBCs. DCLHb caused pulmonary hypertension (from 13 to 30 mmHg) and elevated filling pressure (from 6 to 15 mmHg). Cardiac outputs (CO) were similar for all groups during anesthesia; however, during recovery CO increased only in the LR and packed pRBCs groups. DCLHb may limit the reflex ability to increase CO after volume expansion. Hemodynamic effects of DCLHb may be exaggerated when infused after large-volume LR.
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Affiliation(s)
- Luiz A Vane
- Resuscitation Research Laboratories, Departments of Anesthesiology and Physiology, University of Texas Medical Branch, Galveston, Texas 77555-080, USA
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Orlinsky M, Shoemaker W, Reis ED, Kerstein MD. Current controversies in shock and resuscitation. Surg Clin North Am 2001; 81:1217-62, xi-xii. [PMID: 11766174 DOI: 10.1016/s0039-6109(01)80006-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Many controversies and uncertainties surround resuscitation of hemorrhagic shock caused by vascular trauma. Whereas the basic pathophysiology is better understood, much remains to be learned about the many immunologic cascades that lead to problems beyond those of initial fluid resuscitation or operative hemostasis. Fluid therapy is on the verge of significant advances with substitute oxygen carriers, yet surgeons are still beset with questions of how much and what type of initial fluid to provide. Finally, the parameters chosen to guide therapy and the methods used to monitor patients present other interesting issues.
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Affiliation(s)
- M Orlinsky
- Department of Emergency Medicine, University of Southern California, Keck School of Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles 90033, USA.
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Abstract
For the past 4 decades, the standard approach to the trauma victim who is hypotensive from presumed hemorrhage has been to infuse large volumes of fluids as early and as rapidly as possible. The goals of this treatment strategy are rapid restoration of intravascular volume and vital signs towards normal, and maintenance of vital organ perfusion. The most recent laboratory studies and the only clinical trial evaluating the efficacy of these guidelines however, suggest that in the setting of uncontrolled hemorrhage, today's practice of aggressive fluid resuscitation may be harmful, resulting in increased hemorrhage volume and subsequently greater mortality. This has been demonstrated in animal models representative of penetrating trauma as well as those representative of blunt trauma. The data strongly suggest that limited or hypotensive resuscitation may be preferable for the trauma victim with the potential for ongoing uncontrolled hemorrhage. Limited resuscitation provides a mechanism of avoiding the detrimental effects associated with early aggressive resuscitation, while maintaining a level of tissue perfusion that although decreased from the normal physiologic range is adequate for short periods. Large randomized clinical trials are necessary to confirm this new laboratory data. Future research should focus on developing resuscitation methods that may actually enhance tissue perfusion during limited resuscitation and therefore offset its potential detrimental effects.
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Affiliation(s)
- S A Stern
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan 48109-0303, USA.
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Riess JG. Oxygen carriers ("blood substitutes")--raison d'etre, chemistry, and some physiology. Chem Rev 2001; 101:2797-920. [PMID: 11749396 DOI: 10.1021/cr970143c] [Citation(s) in RCA: 544] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- J G Riess
- MRI Institute, University of California at San Diego, San Diego, CA 92103, USA.
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Spahn DR, Pasch T. Physiological properties of blood substitutes. NEWS IN PHYSIOLOGICAL SCIENCES : AN INTERNATIONAL JOURNAL OF PHYSIOLOGY PRODUCED JOINTLY BY THE INTERNATIONAL UNION OF PHYSIOLOGICAL SCIENCES AND THE AMERICAN PHYSIOLOGICAL SOCIETY 2001; 16:38-41. [PMID: 11390946 DOI: 10.1152/physiologyonline.2001.16.1.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Blood substitutes (modified hemoglobin solutions, perfluorocarbon emulsions) serve as artificial oxygen carriers and are alternatives to blood transfusions. Hemoglobin solutions mimic the sigmoidal oxygen dissociation curve of natural blood. Perfluorocarbon emulsions exhibit a linear relation between PO2 and dissolved oxygen. The most advanced substances may enter medicine in few years.
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Affiliation(s)
- D R Spahn
- Institut für Anästhesiologie, UniversitätsSpital, Rämistrasse 100, CH-8091 Zürich, Switzerland
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Abstract
OBJECTIVE To review current knowledge about cell-free hemoglobin solutions. DATA SOURCES All studies involving cell-free hemoglobin were retrieved from a computerized MEDLINE search from 1980 to 1998. We also reviewed the reference lists of all available review articles and primary studies to identify references not found in the computerized search. STUDY SELECTION Clinical and experimental studies in which cell-free hemoglobin solutions were studied. DATA EXTRACTION From the selected studies, information was obtained regarding the experimental model or the study population in which cell-free hemoglobin solutions were investigated, the type of cell-free hemoglobin solution, their deleterious or beneficial effects, and their possible indications. DATA SYNTHESIS In many studies, hemoglobin solutions were considered as efficient resuscitative agents and good alternatives to red blood cell transfusion, because of their marked vasopressor effect coupled with their capacity to improve the microcirculation and quickly restore metabolic parameters. Nevertheless, potential problems include an increased susceptibility to infection, immunosuppression, oxidative damage, excessive pulmonary and systemic vasoconstriction, and platelet activation. CONCLUSIONS Hemoglobin solutions are more than mere blood substitutes. Promising effects on oxygen transport and the microcirculation need to be confirmed, and the results of continuing research are eagerly awaited.
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Affiliation(s)
- J Creteur
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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Habler O, Kleen M, Pape A, Meisner F, Kemming G, Messmer K. Diaspirin-crosslinked hemoglobin reduces mortality of severe hemorrhagic shock in pigs with critical coronary stenosis. Crit Care Med 2000; 28:1889-98. [PMID: 10890638 DOI: 10.1097/00003246-200006000-00034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effects of resuscitation with a 10% diaspirin-crosslinked hemoglobin (DCLHb) solution on global hemodynamic variables, systemic and myocardial oxygen transport and tissue oxygenation, and contractile function of the left ventricle in an experimental model of severe hemorrhagic shock and critical stenosis of the left anterior descending coronary artery (LAD). DESIGN Prospective, placebo-controlled, randomized study. SETTING Experimental animal laboratory. SUBJECTS A total of 20 anesthetized pigs. INTERVENTIONS After implementation of a permanent critical LAD stenosis (ie, maintenance of basal blood flow but absence of reactive hyperemia after a 10-sec complete vessel occlusion), hemorrhagic shock (target mean aortic pressure, 45 mm Hg) was induced within 15 mins by programmed withdrawal of blood and maintained for 60 mins. Subsequently, the volume of plasma lost during hemorrhage was replaced by either a balanced electrolyte solution containing 10 g/dL DCLHb (DCLHb group; n = 10) or an 8 g/dL human albumin solution (HSA) oncotically matched to DCLHb (HSA group; n = 10). Data were collected immediately after the infusion of the different solutions and again after 60 mins had elapsed. MEASUREMENTS AND MAIN RESULTS Although five of ten HSA-treated animals died of acute left ventricular failure within the first 20 mins after complete fluid resuscitation, all of the DCLHb-treated animals survived the 60-min observation period after resuscitation (p < .05). This significant difference in mortality is explained by higher coronary perfusion pressure in DCLHb-treated animals (75 +/- 17 vs. 27 +/- 17 torr DCLHb vs. HSA group; p < .05) and persistence of subendocardial ischemia and hypoxia (radioactive microspheres method) in HSA-treated animals on resuscitation particularly affecting the LAD-supported myocardium (subendocardial oxygen delivery: 20 +/- 11 vs. 3 +/- 1 mL oxygen x g(-1) x min(-1), DCLHb vs. HSA group; p < .05). Except for enhanced myocardial contractility immediately on infusion of DCLHb (maximal left ventricular pressure increase: 2373 +/- 782 vs. 1730 +/- 543 torr x sec(-1) DCLHb vs. HSA group; p < .05), no differences were detected between groups concerning the variables of systemic oxygen transport, tissue oxygenation, and regional contractile function of the myocardium (determined with microsonometry). CONCLUSIONS Fluid resuscitation with 10% DCLHb solution completely reverses hemorrhagic shock-induced subendocardial ischemia and hypoxia in the presence of compromised coronary circulation and thereby prevents early death after resuscitation.
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Affiliation(s)
- O Habler
- Clinic of Anesthesiology, Ludwig Maximilians University, Munich, Germany.
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Glasgow SC, Shah AS, Noone RB, Gottfried MR, Eachempati SR, Talarico TL, Vaslef SN. Comparison of various hemoglobin polyoxyethylene conjugate solutions as resuscitative fluids after hemorrhagic shock. THE JOURNAL OF TRAUMA 2000; 48:884-92; discussion 892-3. [PMID: 10823532 DOI: 10.1097/00005373-200005000-00012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research suggested that splanchnic hypoperfusion occurs after resuscitation with certain acellular hemoglobin solutions. We examined the influence of maltose content and oxygen affinity on resuscitation with various hemoglobin polyoxyethylene conjugate solutions after hemorrhage. METHODS Fifteen swine underwent hemorrhage and equal volume resuscitation with pyridoxalated hemoglobin polyoxyethylene conjugate containing 0% or 8% maltose, or low P50 conjugate, which also contained 8% maltose. Five control animals were monitored but not bled. Regional blood flow was determined by using radioactive microspheres, gastric mucosal perfusion was estimated with tonometry, and gut histopathology was evaluated. RESULTS All hemoglobin solutions produced vasoconstriction, manifested by elevated mean systemic and pulmonary artery pressures without a significant decrease in cardiac index compared with the sham group. Resuscitation with maltose-containing solutions elevated arterial and regional PCO2 and depressed arterial pH and gastric pHi (p < 0.05 for all). Splanchnic and renal blood flows were reduced in the low P50 + 8% maltose group (p < 0.05 vs. sham and baseline for renal blood flow), possibly indicating greater regional vasoconstriction in this group. Ileal mucosal damage was more severe in the maltose-containing groups and correlated with decreased pHi. CONCLUSION Vasoconstriction occurred in all groups but was more severe in the low P50 + 8% maltose group. Maltose-containing solutions caused respiratory acidosis, decreased pHi, and histologic evidence of mucosal injury. Pyridoxalated hemoglobin polyoxyethylene conjugate without maltose was a superior resuscitation solution in this swine model.
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Affiliation(s)
- S C Glasgow
- Department of Surgery, Wilford Hall Medical Center, Lackland AFB, Texas, USA
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Bruder N, Gouvitsos F. [Vascular loading in the first 24 hours following severe head injuries]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:316-25. [PMID: 10836121 DOI: 10.1016/s0750-7658(99)00151-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The main goal at the acute phase of head injury is to prevent a decrease in blood pressure, which promotes cerebral ischemia. Volume loading is therefore frequently indicated. A normal or increased plasma osmolarity should be maintained. Thus hypotonic fluids should be avoided. Hyperglycaemia is also a risk factor for brain injury and glucose use has to be restricted in the first hours after trauma. Isotonic saline 0.9% is the first solution to be infused. Lactated Ringer solutions are mildly hypotonic as approximately 114 mL of free water is contained in each litre of the solution. Isotonic colloids are indicated to replace blood losses, but have no advantage over cristalloids, concerning the development of cerebral oedema. Fluid restriction minimally affects cerebral edema. Because of the severe consequences of hypovolaemia and hypotension, fluids should not be restricted until haemodynamic stability is achieved. Hypertonic fluids rapidly restore intravascular volume and decrease intracranial pressure. Although they probably have a place in prehospital intensive therapy, the demonstration of their benefit is still lacking. Monitoring of intravascular volume is essential. Continuous arterial pressure and central venous pressure monitoring are mandatory. New monitoring techniques as the measurement of systolic pressure variations or transoesophageal Doppler echocardiography will probably find a place in the management of trauma patients in the near future.
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Affiliation(s)
- N Bruder
- Département d'anesthésie-réanimation, hôpital Timone, Marseille, France
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Friedman HI, Devenuto F, Kerwin A, Carson K, Bynoe R. Hemoglobin solutions as blood substitutes. J INVEST SURG 2000; 13:79-94. [PMID: 10801045 DOI: 10.1080/089419300272122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- H I Friedman
- Department of Surgery, University of South Carolina, School of Medicine, Columbia 29203, USA
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Abstract
Artificial oxygen carriers may be grouped into modified hemoglobin solutions and fluorocarbon emulsions. In animal experiments, both have been shown to be efficacious in improving tissue oxygenation and as substitutes for blood transfusions. Advantages and disadvantages are being discussed in this article as well as the latest steps in the clinical development.
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Affiliation(s)
- D R Spahn
- Institut für Anästhesiologie, UniversitätsSpital, Zürich, Switzerland.
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Kim HW, Greenburg AG. Pharmacodynamic characterization of hemoglobin-induced vasoactivity in isolated rat thoracic aorta. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2000; 135:180-7. [PMID: 10695664 DOI: 10.1067/mlc.2000.104463] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The origin and mechanism of vasocontraction observed after vascular exposure to acellular Hbs remain controversial. To help resolve the underlying mechanism, we characterized Hb-induced vasoactivities in terms of Hb purity, heme iron oxidation state, and ligand and pharmacodynamic properties. Isolated rat thoracic aortic rings with intact endothelium were suspended in oxygenated Krebs buffer, and isometric tension responses to various test Hb preparations were measured. In norepinephrine tone-enhanced aortic rings, both crude and purified Hbs exhibited similar dose-response characteristics; stroma-free Hb and HbA0, two Hb preparations with disparate purity, were equally potent in inducing vessel ring contraction. Purified Hb preparations significantly attenuated vasodilatory potency of both acetylcholine, an endothelium-dependent NO generator, and glyceryl trinitrate, an endothelium-independent NO generator. With the exception of nitrosylated Hb, ferrous Hbs, oxy Hb, and carbon monoxy Hb elicited contraction, whereas ferric derivatives, met Hb, and cyanomet Hb did not. In addition, NEM-Hb, an Hb with blocked cysteine residues, did not notably attenuate Hb vasoactivity. These results indicate that Hb itself is directly responsible for inducing contraction in the rat thoracic aortic rings. A primary mechanism for the Hb-induced vasoactivity appears to be heme iron inactivation of endothelium-derived NO. Nonheme interaction with endothelial NO does not appear to play a prominent role in this vascular model. In conclusion, Hb elicits dose-dependent contraction in isolated rat thoracic aorta with intact endothelium. Vasoactivity of Hbs, however, could greatly vary with heme iron oxidation state, nature of heme ligand, and model vessels used in the evaluation.
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Affiliation(s)
- H W Kim
- Department of Surgery, The Miriam Hospital and Brown University, Providence, RI 02906, USA
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25
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Abstract
Blood transfusion is an essential and ubiquitous component of medical therapy. Despite careful screening and processing, allogeneic blood still carries a small but definable risk of the transmission of severe viral disease and the induction of immunological reactions. The logistics of its storage and transport continue to present a challenge, and its dependence on human donors will always keep it a scarce resource. It is not surprising that in the latter half of the 20th century efforts to develop blood substitutes have gained increasing momentum.
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Affiliation(s)
- A Feit
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, NY, USA
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26
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Fischer SR, Burnet M, Traber DL, Prough DS, Kramer GC. Plasma volume expansion with solutions of hemoglobin, albumin, and Ringer lactate in sheep. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 276:H2194-203. [PMID: 10362704 DOI: 10.1152/ajpheart.1999.276.6.h2194] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have measured plasma volume expansion (Evans blue and hematocrit changes) and hemodynamic responses in conscious hemorrhaged and normovolemic splenectomized sheep after a 30-min infusion of either 20 ml/kg of diaspirin cross-linked hemoglobin (DCLHb), 20 ml/kg of human albumin (Alb), or 60 ml/kg of a solution of Ringer lactate (RL). All regimens expanded blood volume and increased blood pressure and cardiac output after hemorrhage. However, only 15 +/- 3% of the infused volume of RL was evident as intravascular expansion 10-min postinfusion, compared with 67 +/- 16% and 139 +/- 139% for Alb and DCLHb, respectively. DCLHb infusions were associated with higher blood pressures and lower cardiac outputs compared with RL and Alb infusions, but the increased oxygen content of blood with DCLHb resulted in systemic delivery of oxygen similar to that of the other infusions. These differences in hemodynamics and vascular volume continued for 6 h, and at 24 h vascular volume and all hemodynamics were similar in all three groups. The better volume expansion with DCLHb may be due to greater mobilization of endogenous interstitial protein or reduced transcapillary loss as total intravascular endogenous plasma protein increased after infusion of DCLHb, whereas there was an apparent loss of endogenous intravascular protein after infusions of Alb and RL. Vasoconstriction by DCLHb is one mechanism that could lower blood-to-tissue transport of fluid and protein. In addition to its oxygen-carrying capacity and vasoactivity, DCLHb is associated with volume expansion properties out of proportion to its colloid osmotic pressure.
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Affiliation(s)
- S R Fischer
- Department of Anesthesiology, University of Texas Medical Branch and Shriners Burns Hospital, Galveston, Texas 77555, USA
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27
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28
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Baron JF. Blood substitutes. Haemoglobin therapeutics in clinical practice. Crit Care 1999; 3:R99-102. [PMID: 11094489 PMCID: PMC137240 DOI: 10.1186/cc365] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/1999] [Accepted: 09/06/1999] [Indexed: 11/26/2022] Open
Abstract
Early approaches to the development of oxygen carriers involved the use of stroma-free hemoglobin solutions. These solutions did not require blood typing or crossmatching and could be stored for long periods. In addition, a variety of methods have been developed in chemically modifying and stabilizing the hemoglobin molecule. Several hemoglobin therapeutics are now in clinical trials as temporary alternatives to blood or as therapeutic agents for ischemia. The various hemoglobin products under development are derived from three principal sources: human, bovine and genetically engineered hemoglobin. Diaspirin cross-linked hemoglobin (DCLHb), administered at doses ranging from approximately 20-1000 ml, has been investigated in a number of clinical trials in patients undergoing orthopedic, abdominal aortic repair, major abdominal surgery, cardiac surgery and in critically ill patients with septic shock. In several studies, DCLHb was effective in avoiding the transfusion. However, Baxter Healthcare Corporation (Chicago, Illinois, USA) stopped the development of DCLHb after two unsuccessful trials in trauma patients. Bovine polymerized hemoglobin has also been extensively studied. Several phase II and phase III trials have been performed with this product in hemorrhagic surgery, cardiac surgery and vascular surgery, but data have not yet been published. Hemoglobin therapeutics could provide an important new option as an alternative to blood transfusion. Furthermore, they may be able to provide an immediate on-site replacement for traumatic blood loss, prevent global ischemia and organ failure, treat focal ischemia, and provide effective hemodynamic support for septic shock-induced hypotension.
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Conhaim RL, Cooler SD, McGrath AM, DeAngeles DA, Myers GA, Harms BA. Filtration of diaspirin crosslinked hemoglobin into lung and soft tissue lymph. Am J Respir Crit Care Med 1998; 158:1204-12. [PMID: 9769283 DOI: 10.1164/ajrccm.158.4.9705042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Diaspirin crosslinked hemoglobin (DCHb) is a new blood substitute manufactured from human blood. To evaluate its microvascular filtration properties, we infused DCLHb into unanesthetized sheep (10%, 20 ml/kg) and measured the flow and composition of lung and soft tissue lymph. For comparison, we also infused human serum albumin (HSA; 10%, 20 ml/kg). DCLHb raised systemic and pulmonary arterial pressures from baseline values of 83 +/- 7 and 13 +/- 2 mm Hg, respectively, to peak values of 113 +/- 9 and 26 +/- 3 mm Hg (p < 0.05 versus baseline). These increases were significantly greater than those associated with HSA, which raised systemic and pulmonary arterial pressures from baseline values of 86 +/- 4 and 13 +/- 2 mm Hg, respectively, to peak values of 97 +/- 3 and 21 +/- 7 mm Hg (p <= 0.05 versus baseline and versus DCLHb). These differences reflect the known pressor properties of DCLHb. Accordingly, DCLHb raised lung and soft tissue lymph flows to peak values of 12.2 +/- 3.8 and 1.6 +/- 0.7 ml/30 min, respectively, while HSA raised lung and soft tissue lymph flows to peak values of 7.5 +/- 4.8 and 4.6 +/- 1.9 ml/30 min, respectively (p <= 0.05 versus DCLHb). The half-times of DCLHb equilibration from plasma into lung and soft tissue lymph of 1. 0 +/- 0.3 and 2.1 +/- 1.1 h, respectively, were significantly faster than HSA equilibration half-times of 3.1 +/- 0.2 and 3.8 +/- 0.9 h. Filtration differences between DCLHb and HSA appear to be due to the pressor properties DCLHb.
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Affiliation(s)
- R L Conhaim
- Department of Surgery, University of Wisconsin-Madison, and William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
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30
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Lagutchik MS, Ogilvie GK, Hackett TB, Wingfield WE. Increased Lactate Concentrations in III and Injured Dogs. J Vet Emerg Crit Care (San Antonio) 1998. [DOI: 10.1111/j.1476-4431.1998.tb00052.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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