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Paredes RM, Castaneda M, Mireles AA, Rodriguez D, Maddry J. Comparison of hydroxocobalamin with other resuscitative fluids in volume-controlled and uncontrolled hemorrhage models in swine ( Sus-scrofa ). J Trauma Acute Care Surg 2023; 95:S120-S128. [PMID: 37199527 PMCID: PMC10389457 DOI: 10.1097/ta.0000000000004049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Traumatic hemorrhage is the leading cause of preventable death in military environments. Treatment with resuscitative fluids and blood components is based on availability, thus, frequently unavailable in the prehospital setting, due to lack of resources and costs. Hydroxocobalamin (HOC), increases blood pressure via nitric oxide scavenging. We evaluated HOC as a resuscitation fluid, in two swine hemorrhage models. Our objectives were to (1) evaluate whether HOC treatment following hemorrhagic shock improves hemodynamic parameters and (2) determine whether those effects are comparable to whole blood (WB) and lactated ringers (LR). METHODS Yorkshire swine (S us scrofa ) (n = 72) were used in models of controlled hemorrhage (CH) (n = 36) and uncontrolled hemorrhage (UH) (n = 36). Randomized animals received treatment with 500 mL of either WB, LR, HOC (150 mg/kg), followed by a six-hour observation (n = 6 each group). Survival, hemodynamics, blood gases (ABGs) and chemistries were collected. Data reported as mean ± standard error of the mean and statistical analysis by ANOVA ( p < 0.05). RESULTS Blood loss for CH was 41% ± 0.02 versus 33% ± 0.07 for UH. For CH, HOC treatment maintained higher systolic blood pressure (sBP, mm Hg) compared with WB and LR (72 ± 1.1; 60 ± 0.8; 58 ± 1.6; respectively). Heart rate (HR), cardiac output (CO), Sp o2 and vascular resistance were comparable with WB and LR. The ABG values were comparable between HOC and WB. For UH, HOC treatment maintained sBP levels comparable to WB and higher than LR (70 ± 0.9; 73 ± 0.5; 56 ± 1.2). HR, CO, Sp o2 , and systemic vascular resistance were comparable between HOC and WB. Survival, hemodynamics, blood gases were comparable between HOC and WB. No survival differences were found between cohorts. CONCLUSION Hydroxocobalamin treatment improved hemodynamic parameters and Ca 2+ levels compared with LR and equivalent to WB, in both models. Hydroxocobalamin may be a viable alternative when WB is not available.
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Cao M, Zhao Y, He H, Yue R, Pan L, Hu H, Ren Y, Qin Q, Yi X, Yin T, Ma L, Zhang D, Huang X. New Applications of HBOC-201: A 25-Year Review of the Literature. Front Med (Lausanne) 2021; 8:794561. [PMID: 34957164 PMCID: PMC8692657 DOI: 10.3389/fmed.2021.794561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/05/2021] [Indexed: 01/10/2023] Open
Abstract
If not cured promptly, tissue ischemia and hypoxia can cause serious consequences or even threaten the life of the patient. Hemoglobin-based oxygen carrier-201 (HBOC-201), bovine hemoglobin polymerized by glutaraldehyde and stored in a modified Ringer's lactic acid solution, has been investigated as a blood substitute for clinical use. HBOC-201 was approved in South Africa in 2001 to treat patients with low hemoglobin (Hb) levels when red blood cells (RBCs) are contraindicated, rejected, or unavailable. By promoting oxygen diffusion and convective oxygen delivery, HBOC-201 may act as a direct oxygen donor and increase oxygen transfer between RBCs and between RBCs and tissues. Therefore, HBOC-201 is gradually finding applications in treating various ischemic and hypoxic diseases including traumatic hemorrhagic shock, hemolysis, myocardial infarction, cardiopulmonary bypass, perioperative period, organ transplantation, etc. However, side effects such as vasoconstriction and elevated methemoglobin caused by HBOC-201 are major concerns in clinical applications because Hbs are not encapsulated by cell membranes. This study summarizes preclinical and clinical studies of HBOC-201 applied in various clinical scenarios, outlines the relevant mechanisms, highlights potential side effects and solutions, and discusses the application prospects. Randomized trials with large samples need to be further studied to better validate the efficacy, safety, and tolerability of HBOC-201 to the extent where patient-specific treatment strategies would be developed for various clinical scenarios to improve clinical outcomes.
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Affiliation(s)
- Min Cao
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yong Zhao
- Anesthesiology, Southwest Medicine University, Luzhou, China
| | - Hongli He
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Ruiming Yue
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lingai Pan
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Huan Hu
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yingjie Ren
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qin Qin
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xueliang Yi
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Tao Yin
- Surgical Department, Chengdu Second People's Hospital, Chengdu, China
| | - Lina Ma
- Health Inspection and Quarantine, Chengdu Medical College, Chengdu, China
| | - Dingding Zhang
- Sichuan Provincial Key Laboratory for Disease Gene Study, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaobo Huang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Arnaud F, Haque A, Morris MAJE, Moon-Massat P, Auker C, Biswajit S, Hazzard B, Tran Ho LTV, McCarron R, Scultetus A. Treatment of Swine Closed Head Injury with Perfluorocarbon NVX-428. ACTA ACUST UNITED AC 2020; 8:medsci8040041. [PMID: 32992571 PMCID: PMC7712073 DOI: 10.3390/medsci8040041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/17/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022]
Abstract
Pre-hospital treatment of traumatic brain injury (TBI) with co-existing polytrauma is complicated by requirements for intravenous fluid volume vs. hypotensive resuscitation. A low volume, small particle-size-oxygen-carrier perfluorocarbon emulsion NVX-428 (dodecafluoropentane emulsion; 2% w/v) could improve brain tissue with minimal additional fluid volume. This study examined whether the oxygen-carrier NVX-428 shows safety and efficacy for pre-hospital treatment of TBI. Anesthetized swine underwent fluid percussion injury TBI and received 1 mL/kg IV NVX-428 (TBI-NVX) at 15 min (T15) or normal saline (no-treatment) (TBI-NON). Similarly, uninjured swine received NVX-428 (SHAM-NVX) or normal saline (SHAM-NON). Animals were monitored and measurements were taken for physiological and neurological parameters before euthanasia at the six-hour mark (T360). Histopathological analysis was performed on paraffin embedded tissues. Physiological, biochemical and blood gas parameters were not different, with the exception of a significant but transient increase in mean pulmonary artery pressure observed in the TBI-experimental group immediately after drug administration. There were no initial differences in brain oxygenation at baseline, but over time oxygen decreased ~50% in both TBI groups. Histological brain injury scores were similar between TBI-NVX and TBI-NON, although a number of subcategories (spongiosis-ischemic/dead neurons-hemorrhage-edema) in TBI-NVX had a tendency for lower scores. The cerebellum showed significantly lower spongiosis and ischemic/dead neuron injury scores and a lower number of Fluoro-Jade-B-positive cerebellar-Purkinje-cells after NVX-428 treatment compared to controls. NVX-428 may assist in mitigating secondary cellular brain damage.
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Affiliation(s)
- Francoise Arnaud
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720 Rockledge Drive, Bethesda, MD 20817, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA
- Correspondence: ; Tel.: +301-319-7687
| | - Ashraful Haque
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720 Rockledge Drive, Bethesda, MD 20817, USA
| | - MAJ Erin Morris
- Walter Reed Army Institute of Research, Veterinary Pathology Services, 503 Robert Grant Ave, Silver Spring, MD 20910, USA;
| | - Paula Moon-Massat
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720 Rockledge Drive, Bethesda, MD 20817, USA
| | - Charles Auker
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720 Rockledge Drive, Bethesda, MD 20817, USA
| | - Saha Biswajit
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720 Rockledge Drive, Bethesda, MD 20817, USA
| | - Brittany Hazzard
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720 Rockledge Drive, Bethesda, MD 20817, USA
| | - Lam Thuy Vi Tran Ho
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., 6720 Rockledge Drive, Bethesda, MD 20817, USA
| | - Richard McCarron
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA
| | - Anke Scultetus
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Ave, Silver Spring, MD 20910, USA; (A.H.); (P.M.-M.); (C.A.); (S.B.); (B.H.); (L.T.V.T.H.); (R.M.); (A.S.)
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA
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Hagisawa K, Kinoshita M, Saitoh D, Morimoto Y, Sakai H. Intraosseous transfusion of hemoglobin vesicles in the treatment of hemorrhagic shock with collapsed vessels in a rabbit model. Transfusion 2020; 60:1400-1409. [PMID: 32579275 DOI: 10.1111/trf.15915] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/16/2020] [Accepted: 05/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUNDS Intravenous transfusion sometimes encounters difficulty under prehospital conditions when peripheral vessels are collapsed and inaccessible. We investigated whether the cellular type hemoglobin-based oxygen carriers (Hemoglobin Vesicles: HbVs) allow intraosseous administration into blood circulation for the resuscitation of rabbits with severe hemorrhagic shock. STUDY DESIGN AND METHODS New Zealand white rabbits (2.5 kg average) were set in severe hemorrhagic shock [mean arterial pressure (MAP): 21 ± 2 mm Hg, Hb 5.1 ± 0.8 g/dL]. Immediately thereafter, 12 mL/kg of HbVs, 5% human serum albumin (HSA), autologous whole blood (WB), stored red blood cells (RBCs) or 36 mL/kg of Lactated Ringer's (LR) were intraosseously transfused, followed by an additional intraosseous transfusion with 8 mL/kg of HSA (following HbV, HSA or stored RBC transfusion), or WB or 24 mL/kg of LR (following LR transfusion), respectively. RESULTS Intraosseous transfusion of HbVs increased MAP (48 ± 9 mm Hg) and improved hypohemoglobinemia (7.1 ± 0.6 g/dL) as well as WB or RBC transfusion. In contrast, neither HSA nor LR improved hemodynamics or Hb levels. Seven out of 10 rabbits receiving HbVs survived for 24 hours, while only one out of 10 rabbits receiving LR survived (WB and RBC; 100% survivals, HSA; 30% survival). CONCLUSIONS Intraosseous infusion of HbVs might be an effective initial treatment to maintain hemodynamics during acute hemorrhagic shock. This approach could be used in emergency situations in which access to peripheral vessels is difficult.
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Affiliation(s)
- Kohsuke Hagisawa
- Department of Physiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Daizoh Saitoh
- Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Saitama, Japan
| | - Yuji Morimoto
- Department of Physiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hiromi Sakai
- Department of Chemistry, Nara Medical University, Kashihara, Nara, Japan
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Dickson JM, Wang X, St John AE, Lim EB, Stern SA, White NJ. Damage Control Resuscitation Supplemented with Vasopressin in a Severe Polytrauma Model with Traumatic Brain Injury and Uncontrolled Internal Hemorrhage. Mil Med 2019; 183:e460-e466. [PMID: 29547998 DOI: 10.1093/milmed/usy001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/27/2017] [Accepted: 01/01/2018] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) and hemorrhagic shock (HS) are the leading causes of traumatic death worldwide and particularly on the battlefield. They are especially challenging when present simultaneously (polytrauma), and clear blood pressure end points during fluid resuscitation are not well described for this situation. The goal of this study is to evaluate for any benefit of increasing blood pressure using a vasopressor on brain blood flow during initial fluid resuscitation in a swine polytrauma model. MATERIALS AND METHODS We used a swine polytrauma model with simultaneous TBI, femur fracture, and HS with uncontrolled noncompressible internal bleeding from an aortic tear injury. Five animals were assigned to each of three experimental groups (hydroxyethyl starch only [HES], HES + 0.4 U/kg vasopressin, and no fluid resuscitation [No Fluids]). Fluids were given as two 10 mL/kg boluses according to tactical field care guidelines. Primary outcomes were mean arterial blood pressure (MAP) and brain blood flow at 60 min. Secondary outcomes were blood flows in the heart, intestine, and kidney; arterial blood lactate level; and survival at 6 hr. Organ blood flow was measured using injection of colored microspheres. RESULTS Five animals were tested in each of the three groups. There was a statistically significant increase in MAP with vasopressin compared with other experimental groups, but no significant increase in brain blood flow during the first 60 min of resuscitation. The vasopressin group also exhibited greater total internal hemorrhage volume and rate. There was no difference in survival at 6 hours. CONCLUSION In this experimental swine polytrauma model, increasing blood pressure with vasopressin did not improve brain perfusion, likely due to increased internal hemorrhage. Effective hemostasis should remain the top priority for field treatment of the polytrauma casualty with TBI.
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Affiliation(s)
- J Michael Dickson
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA.,18D at 19th Special Forces Group (Airborne) & former 18D at 1st Special Forces Group (Airborne) JB Lewis-McChord, WA
| | - Xu Wang
- Department of Emergency Medicine, University of Washington and Harborview Medical Center, Box 359702 325 9th Ave, Seattle, WA
| | - Alexander E St John
- Department of Emergency Medicine, University of Washington and Harborview Medical Center, Box 359702 325 9th Ave, Seattle, WA
| | - Esther B Lim
- Department of Emergency Medicine, University of Washington and Harborview Medical Center, Box 359702 325 9th Ave, Seattle, WA
| | - Susan A Stern
- Department of Emergency Medicine, University of Washington and Harborview Medical Center, Box 359702 325 9th Ave, Seattle, WA
| | - Nathan J White
- Department of Emergency Medicine, University of Washington and Harborview Medical Center, Box 359702 325 9th Ave, Seattle, WA
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Mayer AR, Dodd AB, Vermillion MS, Stephenson DD, Chaudry IH, Bragin DE, Gigliotti AP, Dodd RJ, Wasserott BC, Shukla P, Kinsler R, Alonzo SM. A systematic review of large animal models of combined traumatic brain injury and hemorrhagic shock. Neurosci Biobehav Rev 2019; 104:160-177. [PMID: 31255665 PMCID: PMC7307133 DOI: 10.1016/j.neubiorev.2019.06.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 01/08/2023]
Abstract
Traumatic brain injury (TBI) and severe blood loss (SBL) frequently co-occur in human trauma, resulting in high levels of mortality and morbidity. Importantly, each of the individual post-injury cascades is characterized by complex and potentially opposing pathophysiological responses, complicating optimal resuscitation and therapeutic approaches. Large animal models of poly-neurotrauma closely mimic human physiology, but a systematic literature review of published models has been lacking. The current review suggests a relative paucity of large animal poly-neurotrauma studies (N = 52), with meta-statistics revealing trends for animal species (exclusively swine), characteristics (use of single biological sex, use of juveniles) and TBI models. Although most studies have targeted blood loss volumes of 35-45%, the associated mortality rates are much lower relative to Class III/IV human trauma. This discrepancy may result from potentially mitigating experimental factors (e.g., mechanical ventilation prior to or during injury, pausing/resuming blood loss based on physiological parameters, administration of small volume fluid resuscitation) that are rarely associated with human trauma, highlighting the need for additional work in this area.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States; Neurology Department, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States; Psychiatry Department, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States; Psychology Department, University of New Mexico, Albuquerque, NM 87131, United States.
| | - Andrew B Dodd
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
| | - Meghan S Vermillion
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
| | - David D Stephenson
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
| | - Irshad H Chaudry
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294-0019, United States
| | - Denis E Bragin
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Andrew P Gigliotti
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
| | - Rebecca J Dodd
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
| | - Benjamin C Wasserott
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
| | - Priyank Shukla
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
| | - Rachel Kinsler
- Department of the Army Civilian, U.S. Army Aeromedical Research Laboratory, Fort Rucker, AL 36362-0577, United States
| | - Sheila M Alonzo
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, 1011 Yale Blvd. NE, Albuquerque, NM 87106, United States
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Modeling Acute Traumatic Hemorrhagic Shock Injury: Challenges and Guidelines for Preclinical Studies. Shock 2017; 48:610-623. [DOI: 10.1097/shk.0000000000000901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Simon DW, Vagni VM, Kochanek PM, Clark RSB. Combined Neurotrauma Models: Experimental Models Combining Traumatic Brain Injury and Secondary Insults. Methods Mol Biol 2016; 1462:393-411. [PMID: 27604730 DOI: 10.1007/978-1-4939-3816-2_22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Patients with severe traumatic brain injury (TBI) frequently present with concomitant injuries that may cause secondary brain injury and impact outcomes. Animal models have been developed that combine contemporary models of TBI with a secondary neurologic insult such as hypoxia, shock, long bone fracture, and radiation exposure. Combined injury models may be particularly useful when modeling treatment strategies and in efforts to map basic research to a heterogeneous patient population. Here, we review these models and their collective contribution to the literature on TBI. In addition, we provide protocols and notes for two well-characterized models of TBI plus hemorrhagic shock.
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Affiliation(s)
- Dennis W Simon
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Vincent M Vagni
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Fibrinogen concentrate improves survival during limited resuscitation of uncontrolled hemorrhagic shock in a Swine model. Shock 2015; 42:456-63. [PMID: 25337778 DOI: 10.1097/shk.0000000000000238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to evaluate the effect of fibrinogen concentrate, as a hemostatic agent, on limited resuscitation of uncontrolled hemorrhagic shock. We use a swine model of hemorrhagic shock with free bleeding from a 4-mm aortic tear to test the effect of adding a one-time dose of fibrinogen concentrate given at the onset of limited fluid resuscitation. Immature female swine were anesthetized and subjected to catheter hemorrhage and aortic tear to induce uniform hemorrhagic shock. Animals (n = 7 per group) were then randomized to receive (i) no fluid resuscitation (neg control) or (ii) limited resuscitation in the form of two boluses of 10 mL/kg of 6% hydroxyethyl starch solution given 30 min apart (HEX group), or (iii) the same fluid regimen with one dose of 120-mg/kg fibrinogen concentrate given with the first hydroxyethyl starch bolus (FBG). Animals were then observed for a total of 6 h with aortic repair and aggressive resuscitation with shed blood taking place at 3 h. Survival to 6 h was significantly increased with FBG (7/8, 86%) versus HEX (2/7, 29%) and neg control (0/7, 0%) (FBG vs. HEX, Kaplan-Meier log-rank P = 0.035). Intraperitoneal blood loss adjusted for survival time was increased in HEX (0.4 mL/kg per minute) when compared with FBG (0.1 mg/kg per minute, P = 0.047) and neg control (0.1 mL/kg per minute, P = 0.041). Systemic and cerebral hemodynamics also showed improvement with FBG versus HEX. Fibrinogen concentrate may be a useful adjunct to decrease blood loss, improve hemodynamics, and prolong survival during limited resuscitation of uncontrolled hemorrhagic shock.
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Bebarta VS, Garrett N, Boudreau S, Castaneda M. A prospective, randomized trial of intravenous hydroxocobalamin versus whole blood transfusion compared to no treatment for Class III hemorrhagic shock resuscitation in a prehospital swine model. Acad Emerg Med 2015; 22:321-30. [PMID: 25731610 DOI: 10.1111/acem.12605] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 09/03/2014] [Accepted: 10/29/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The objective was to compare systolic blood pressure (sBP) over time in swine that have had 30% of their blood volume removed (Class III shock) and treated with intravenous (IV) whole blood or IV hydroxocobalamin, compared to nontreated control animals. METHODS Thirty swine (45 to 55 kg) were anesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged a total of 20 mL/kg over a 20-minute period. Five minutes after hemorrhage, animals were randomly assigned to receive 150 mg/kg IV hydroxocobalamin solubilized in 180 mL of saline, 500 mL of whole blood, or no treatment. Animals were monitored for 60 minutes thereafter. A sample size of 10 animals per group was determined based on a power of 80% and an alpha of 0.05 to detect an effect size of at least a 0.25 difference (>1 standard deviation) in mean sBP between groups. sBP values were analyzed using repeated-measures analysis of variance (RANOVA). Secondary outcome data were analyzed using repeated-measures multivariate analysis of variance (RMANOVA). RESULTS There were no significant differences between hemodynamic parameters of IV hydroxocobalamin versus whole blood versus control group at baseline (MANOVA; Wilks' lambda; p = 0.868) or immediately posthemorrhage (mean sBP = 47 mm Hg vs. 41 mm Hg vs. 37 mm Hg; mean arterial pressure = 39 mm Hg vs. 28 mm Hg vs. 34 mm Hg; mean serum lactate = 1.2 mmol/L vs. 1.4 mmol/L vs. 1.4 mmol/L; MANOVA; Wilks' lambda; p = 0.348). The outcome RANOVA model detected a significant difference by time between groups (p < 0.001). Specifically, 10 minutes after treatment, treated animals showed a significant increase in mean sBP compared to nontreated animals (mean sBP = 76.3 mm Hg vs. 85.7 mm Hg vs. 51.1 mm Hg; p < 0.001). RMANOVA modeling of the secondary data detected a significant difference in mean arterial pressure, heart rate, and serum lactate (p < 0.001). Similar to sBP, 10 minutes after treatment, treated animals showed a significant increase in mean arterial pressure compared to nontreated animals (mean arterial pressure = 67.7 mm Hg vs. 61.4 mm Hg vs. 40.5 mm Hg). By 10 minutes, mean heart rate was significantly slower in treated animals compared to nontreated animals (mean heart rate = 97.3 beats/min vs. 95.2 beats/min vs. 129.5 beats/min; p < 0.05). Serum lactate, an early predictor of shock, continued to rise in the control group, whereas it did not in treated animals. Thirty minutes after treatment, serum lactate values of treated animals were significantly lower compared to nontreated animals (p < 0.05). This trend continued throughout the 60-minute observation period such that 60-minute values for lactate were 1.4 mmol/L versus 1.1 mmol/L versus 3.8 mmol/L. IV hydroxocobalamin produced a statistically significant increase in systemic vascular resistance compared to control, but not whole blood, with a concomitant decrease in cardiac output. CONCLUSIONS Intravenous hydroxocobalamin was more effective than no treatment and as effective as whole blood transfusion, in reversing hypotension and inhibiting rises in serum lactate in this prehospital, controlled, Class III swine hemorrhage model.
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Affiliation(s)
- Vikhyat S. Bebarta
- The Department of Emergency Medicine; CREST Research Program; San Antonio Military Medical Center; San Antonio TX
- Enroute Care Research Center; US Army; Institute of Surgical Research; San Antonio TX
| | - Normalynn Garrett
- The Department of Emergency Medicine; CREST Research Program; San Antonio Military Medical Center; San Antonio TX
| | - Susan Boudreau
- The Department of Emergency Medicine; CREST Research Program; San Antonio Military Medical Center; San Antonio TX
| | - Maria Castaneda
- The Department of Emergency Medicine; CREST Research Program; San Antonio Military Medical Center; San Antonio TX
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Abstract
BACKGROUND Hemorrhage persists as the leading cause of potentially preventable civilian and military death. Noncompressible torso hemorrhage (NCTH) is a particularly lethal injury complex, with few contemporary prehospital interventions available. Various porcine models of hemorrhage have been developed for civilian and military trauma research. However, the predominant contemporary models lack key physiologic characteristics including the natural tamponade provided by an intact abdominal wall.To improve physiologic and clinical relevance, we developed a laparoscopic model of NCTH. This approach maintains both the integrity of the peritoneum and the natural tamponade effect of an intact abdominal wall while preserving the intrinsic physiologic responses to hemorrhage. Furthermore, we present data quantifying the contribution of the swine contractile spleen in the context of uncontrolled hemorrhage. METHODS Anesthetized adult male Yorkshire swine underwent a laparoscopic Grade V liver injury, with or without open preinjury splenectomy. Animals were observed without intervention for a total of 120 minutes after injury to simulate point of injury, transport time, and arrival at hospital. RESULTS Shed blood-to-body weight ratio did not differ among groups; however, mortality was higher in splenectomized animals (67% vs. 33%). Cox regression modeling demonstrated a critical time point of 45 minutes and blood pressure as significant predictors of mortality. CONCLUSION This study describes a model of NCTH that reflects clinically relevant physiology in trauma and uncontrolled hemorrhage. In addition, it quantitatively assesses the role of the swine contractile spleen in the described model.
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Abstract
The majority of injury combinations in multiply injured patients entail the chest, abdomen, and extremities. Numerous pig models focus on the investigation of posttraumatic pathophysiology, organ performance monitoring and on potential treatment options. Depending on the experimental question, previous authors have included isolated insults (controlled or uncontrolled hemorrhage, chest trauma) or a combination of these injuries (hemorrhage with abdominal trauma, chest trauma, traumatic brain injury, and/or long-bone fractures). Combined trauma models in pigs can provide a high level of clinical relevance, when they are properly designed and mimicking the clinical situation. Most of these models focus on the first hours after trauma, to assess the acute sequel of traumatic hemorrhage. However, hemorrhagic shock and the associated mass transfusion are also major causes for organ failure and mortality in the later clinical course. Thus, most models lack information on the pathomechanisms during the late posttraumatic phase. Studying new therapies only during the early phase is also not reflective of the clinical situation. Therefore, a longer observation period is required to study the effects of therapeutic approaches during intensive care treatment when using animal models. These long-term studies of combined trauma models will allow the development of valuable therapeutic approaches relevant for the later posttraumatic course. This review summarizes the existing porcine models and outlines the need for long-term models to provide real effective novel therapeutics for multiply injured patients to improve organ function and clinical outcome.
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Assessment of coagulopathy, endothelial injury, and inflammation after traumatic brain injury and hemorrhage in a porcine model. J Trauma Acute Care Surg 2014; 76:12-9; discussion 19-20. [PMID: 24368352 DOI: 10.1097/ta.0b013e3182aaa675] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) and hemorrhagic shock (HS) can be associated with coagulopathy and inflammation, but the mechanisms are poorly understood. We hypothesized that a combination of TBI and HS would disturb coagulation, damage the endothelium, and activate inflammatory and complement systems. METHODS A total of 33 swine were allocated to either TBI + HS (n = 27, TBI and volume-controlled 40% blood loss) or controls (n = 6, anesthesia and instrumentation). TBI + HS animals were left hypotensive (mean arterial pressure, 30-35 mm Hg) for 2 hours. Blood samples were drawn at baseline, 3 minutes and 15 minutes after injury, as well as following 2 hours of hypotension. Markers of coagulation, anticoagulation, endothelial activation/glycocalyx shedding, inflammation, complement, and sympathoadrenal function were measured. RESULTS The TBI + HS group demonstrated an immediate (3 minutes after injury) activation of coagulation (prothrombin fragment 1 + 2, 289 ng/mL vs. 232 ng/mL, p = 0.03) and complement (C5a, 2.83 ng/mL vs. 2.05 ng/mL, p = 0.05). Shedding of the endothelial glycocalyx (syndecan 1) was evident 15 minutes after injury (851.0 ng/ml vs. 715.5 ng/ml, p = 0.03) while inflammation (tumor necrosis factor α [TNF-α], 81.1 pg/mL vs. 50.8 pg/mL, p = 0.03) and activation of the protein C system (activated protein C, 56.7 ng/mL vs. 26.1 ng/mL, p = 0.01) were evident following the 2-hour hypotension phase. CONCLUSION The combination of TBI and shock results in an immediate activation of coagulation and complement systems with subsequent endothelial shedding, protein C activation, and inflammation.
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Cheng Q, Yang G, Ma J, Li J, Shan Q. Effects of different types of fluid resuscitation on hepatic mitochondria and apoptosis. Exp Ther Med 2013; 7:335-342. [PMID: 24396400 PMCID: PMC3881054 DOI: 10.3892/etm.2013.1447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 10/24/2013] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to observe the effects of different types of fluid resuscitation on hepatic mitochondria and apoptosis in hemorrhagic shock, and the corresponding mechanisms. Forty rats were divided into five groups: Sham surgery (Sham group), shock (Shock group), Ringer's lactate resuscitation (RL group), hydroxyethyl starch resuscitation (HES group) and autologous blood resuscitation (BL group). A model of hemorrhagic shock was successfully induced in the latter four groups. The recovery objective was to maintain the mean arterial pressure (MAP) of the rats at 80 mmHg. Two hours after the end of the recovery experiment, fresh liver samples were examined in order to observe the changes in the morphology and mitochondrial membrane potential (ΔΨm). In addition, the levels of succinate dehydrogenase (SDH) activity were assessed, and a terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay was conducted to evaluate the level of apoptosis in the liver cells. In the Shock, RL, HES and BL groups, mitochondrial ultrastructural damage in the liver cells, significant reductions in liver cell function, liver ΔΨm and SDH activity, and the apoptosis of hepatocytes were more apparent compared with those in the Sham group. In the BL group, compared with the RL and HES groups, the injuries to the mitochondrial ultrastructure and liver cell function were significantly reduced, the hepatic ΔΨm and SDH activity were significantly increased and the hepatocyte apoptosis index (AI) was significantly reduced (P<0.05). In conclusion, in a rat model of hemorrhagic shock, different methods of fluid resuscitation may improve the liver cells with regard to mitochondrial ultrastructure and function, the stability of liver ΔΨm, the activity of SDH and the inhibition of liver cell apoptosis. The results indicate that infusion with autologous blood followed by RL solution is a preferable method of fluid resuscitation compared with HES.
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Affiliation(s)
- Qinghong Cheng
- Department of Intensive Care Unit, First Affiliated Hospital, Medical College, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Guangtian Yang
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Juanzhen Ma
- Department of Intensive Care Unit, First Affiliated Hospital, Medical College, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Jianhua Li
- Department of Intensive Care Unit, First Affiliated Hospital, Medical College, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Qi Shan
- Department of Intensive Care Unit, First Affiliated Hospital, Medical College, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
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