Improved survival time with combined early blood transfusion and fluid administration in uncontrolled hemorrhagic shock in rats

Intravital Imaging of Leukocyte-Endothelial Interaction in Hindlimb Ischemia/Reperfusion Injury by Intravital Multiphoton Microscopy

Ischemia/reperfusion injury in skeletal muscle leads to sterile inflammation and affects structure and function permanently. However, the main understanding of the molecular and cellular mechanisms mainly relies on in vitro and ex vivo investigations. Recent advances in intravital microscopy allow for insights into dynamic processes at the cellular and subcellular level under both physiological and pathophysiological conditions. Real-time intravital imaging by two-photon microscopy (2P-IVM) has emerged as a powerful tool in the evaluation of the cell-cell interaction and molecular biology of leukocytes in live animals. Acute ischemic injury in limbs may occur due to crush syndrome, compartment syndrome, and vascular diseases and injury as in acute peripheral arterial occlusion, caused by a diverse array of pathological conditions. Iatrogenic revascularization and restoration of perfusion results paradoxically in aggravated tissue injury. Furthermore, the effects of IR-injured skeletal muscle in clinical conditions such as compartment syndrome or crush syndrome may induce rhabdomyolysis and are associated with so-called remote injuries as acute kidney dysfunction. Here, we discuss the considerations for and describe a 2P-IVM method designed for visualization of leukocyte-endothelial interaction. This chapter will provide a detailed experimental setup and a step-by-step protocol for the dynamic imaging of leukocyte-endothelial-interaction in an ischemia/reperfusion injury model.

Hemodilution as a result of aggressive fluid resuscitation aggravates coagulopathy in a rat model of uncontrolled hemorrhagic shock

BACKGROUND

The relationship between dilution caused by fluid resuscitation and blood coagulability during ongoing, uncontrolled hemorrhagic shock (UHS) remains unclear. We hypothesized that dilution caused by fluid resuscitation may impair blood coagulability in UHS.

METHODS

Eighteen rats underwent under halothane anesthesia. The UHS model consisted of the following phases: (1) an initial blood withdrawal of 2.5 mL per 100 g during 15 minutes, followed by UHS via tail amputation and fluid resuscitation with lactated Ringer's (LR) solution (0-60 minutes); (2) hemostasis and reinfusion of withdrawn blood and additional LR solution (60-100 minutes); and (3) observation of awake rats for 72 hours. Rats were randomized into three resuscitation regimens (n = 6 per group) during Phase I. LR solution was infused at a rate of 0.1 mL/min in Group 1, 0.25 mL/min in Group 2, and 0.75 mL/min in Group 3. Blood coagulability was assessed with a Sonoclot analysis, and survival to 72 hours were compared between groups.

RESULTS

Both resuscitation regimens of Groups 2 and 3 increased the blood pressure and bleeding volume from the tail stump compared with Group 1 (p < 0.05). At the end of Phase I, the hematocrit decreased to 29% (3%) in Group 1, 23% (3%) in Group 2, and 12% (3%) in Group 3 (p < 0.05). Sonoclot analysis revealed a decreased clot rate of 16 (9) clot signal per minute in Group 2 and 14 (10) clot signal per minute in Group 3 compared with Group 1 (40 [10] clot signal per minute; p < 0.01). There was a significant correlation between clot rate and hematocrit values (r = +0.67, p < 0.01). Compared with Group 1, survival improved in Groups 2 and 3 (p < 0.05).

CONCLUSION

In a rat model of UHS, aggressive fluid resuscitation aggravated hemodilution and blood coagulability as well as and bleeding but improved the hemodynamics and survival. There was a positive correlation between hemodilution and coagulation indexes. Hemodilution, as part of fluid therapy, may affect coagulopathy in UHS.

Hemorrhagic shock: The "physiology approach"

A shift of approach from ‘clinics trying to fit physiology’ to the one of ‘physiology to clinics’, with interpretation of the clinical phenomena from their physiological bases to the tip of the clinical iceberg, and a management exclusively based on modulation of physiology, is finally surging as the safest and most efficacious philosophy in hemorrhagic shock. ATLS^® classification and recommendations on hemorrhagic shock are not helpful because antiphysiological and potentially misleading. Hemorrhagic shock needs to be reclassified in the direction of usefulness and timing of intervention: in particular its assessment and management need to be tailored to physiology.

Effects of volume and composition of the resuscitative fluids in the treatment of hemorrhagic shock

Objectives:

To evaluate the effectiveness of normal saline, hypertonic saline, and Ringer's lactate solution followed by blood infusion in ameliorating the physiological, biochemical, and organ functions following hemorrhagic shock (HS) in rats.

Materials and Methods:

Anesthetized, male Sprague-Dawley rats underwent computer-controlled HS, and were randomly divided into five groups consisting of (1) sham, (2) HS without resuscitation, (3) resuscitation with normal saline, (4) resuscitation with hypertonic saline, and (5) resuscitation with Ringer's lactate solution. All resuscitated animals were infused with subsequent infusion of shed blood. Animals were continuously monitored for physiological, hemodynamic, biochemical parameters, and organ dysfunctions.

Results:

Non-resuscitated animals were unable to survive due to hypotension, poor oxygen metabolism, and lactic acidosis. Although these HS related parameters were corrected by all the fluids used in this study, additional blood infusion was more effective than fluid resuscitation alone. Also, hypertonic saline was more effective than Ringer's lactate solution, and normal saline was the least effective in preserving the liver and kidney functions and muscle damage.

Conclusions:

All crystalloid fluids were significantly more effective in reversing the HS outcome when used with blood infusion, but hypertonic salinewith blood was more effective in preventing the organ damage than Lactated Ringers solutions or normal saline in the treatment of HS.

Effects of arterial oxygen content on oxidative stress during resuscitation in a rat hemorrhagic shock model

OBJECTIVE

To examine whether reactive oxygen species (ROS) production is affected by arterial oxygen content (CaO(2)) in attempted resuscitation to restore blood pressure from hemorrhagic shock (HS) or not.

METHODS

Under light anesthesia and spontaneous beating, 16 rats underwent HS for 80min, during which 3.0mL/100g of blood was withdrawn, followed by resuscitation attempt for 70min. At 80min, rats were randomized into a high-CaO(2) group (Group 1, transfusion under fractional inspired oxygen (F(I)O(2)) of 1.0, n=8) or a low-CaO(2) group (Group 2, fluid administration under F(I)O(2) of 0.21, n=8). In each group, either blood or lactate Ringer's (LR) solution was infused to maintain mean arterial pressure ≥75mmHg under each F(I)O(2) concentration. CaO(2), O(2) utilization coefficient (UC) and plasma %CoQ9 were compared between groups.

RESULTS

Mean infused volume for attempted resuscitation was 7.6±1.0mL of blood in Group 1, and 31.4±5.5mL of LR solution in Group 2. At the end of resuscitation, CaO(2) was 18.5±1.2 vol% in Group 1, almost double the 9.1±0.8 vol% in Group 2 (P<0.01). O(2) UC and %CoQ9 in all rats increased from baselines of 0.25±0.12 and 7.6±1.8% to 0.44±0.13 and 9.7±1.8% after resuscitation, respectively (P<0.05 vs. baseline for each), but did not differ significantly between the groups.

CONCLUSION

In a rat HS model, attempted resuscitation to restore blood pressure increased O(2) UC as well as %CoQ9. However, the magnitude of %CoQ9 increase that represents ROS production is not affected by CaO(2) during resuscitation from HS.