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Gil-Anton J, Mielgo VE, Rey-Santano C, Galbarriatu L, Santos C, Unceta M, López-Fernández Y, Redondo S, Morteruel E. Addition of terlipressin to initial volume resuscitation in a pediatric model of hemorrhagic shock improves hemodynamics and cerebral perfusion. PLoS One 2020; 15:e0235084. [PMID: 32614837 PMCID: PMC7332053 DOI: 10.1371/journal.pone.0235084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/08/2020] [Indexed: 11/18/2022] Open
Abstract
Hemorrhagic shock is one of the leading causes of mortality and morbidity in pediatric trauma. Current treatment based on volume resuscitation is associated to adverse effects, and it has been proposed that vasopressors may be used in the pharmacological management of trauma. Terlipressin has demonstrated its usefulness in other pediatric critical care scenarios and its long half-life allows its use as a bolus in an outpatient critical settings. The aim of this study was to analyze whether the addition of a dose of terlipressin to the initial volume expansion produces an improvement in hemodynamic and cerebral perfusion at early stages of hemorrhagic shock in an infant animal model. We conducted an experimental randomized animal study with 1-month old pigs. After 30 minutes of hypotension (mean arterial blood pressure [MAP]<45 mmHg) induced by the withdrawal of blood over 30 min, animals were randomized to receive either normal saline (NS) 30 mL/kg (n = 8) or a bolus of 20 mcg/kg of terlipressin plus 30 mL/kg of normal saline (TP) (n = 8). Global hemodynamic and cerebral monitoring parameters, brain damage markers and histology samples were compared. After controlled bleeding, significant decreases were observed in MAP, cardiac index (CI), central venous pressure, global end-diastolic volume index (GEDI), left cardiac output index, SvO2, intracranial pressure, carotid blood flow, bispectral index (BIS), cerebral perfusion pressure (CPP) and increases in systemic vascular resistance index, heart rate and lactate. After treatment, MAP, GEDI, CI, CPP and BIS remained significantly higher in the TP group. The addition of a dose of terlipressin to initial fluid resuscitation was associated with hemodynamic improvement, intracranial pressure maintenance and better cerebral perfusion, which would mean protection from ischemic injury. Brain monitoring through BIS was able to detect changes caused by hemorrhagic shock and treatment.
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Affiliation(s)
- Javier Gil-Anton
- Department of Pediatric, Pediatric Intensive Care Unit. Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of Basque Country, UPV/EHU, Barakaldo, Bizkaia, Spain
- * E-mail: (VEM); (JGA)
| | - Victoria E. Mielgo
- Animal Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
- * E-mail: (VEM); (JGA)
| | - Carmen Rey-Santano
- Animal Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - Lara Galbarriatu
- Department of Neurosurgery, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Carlos Santos
- Department of Neurophysiology, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Maria Unceta
- Biochemistry Laboratory, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Yolanda López-Fernández
- Pediatric Intensive Care Unit. Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Silvia Redondo
- Pediatric Intensive Care Unit. Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Elvira Morteruel
- Pediatric Intensive Care Unit. Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Bizkaia, Spain
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Ida KK, Otsuki DA, Sasaki ATC, Borges ES, Castro LUC, Sanches TR, Shimizu MHM, Andrade LC, Auler JOC, Dyson A, Smith KJ, Rocha Filho JA, Malbouisson LMS. Effects of terlipressin as early treatment for protection of brain in a model of haemorrhagic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:107. [PMID: 25888229 PMCID: PMC4373118 DOI: 10.1186/s13054-015-0825-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/19/2015] [Indexed: 01/01/2023]
Abstract
Introduction We investigated whether treatment with terlipressin during recovery from hypotension due to haemorrhagic shock (HS) is effective in restoring cerebral perfusion pressure (CPP) and brain tissue markers of water balance, oxidative stress and apoptosis. Methods In this randomised controlled study, animals undergoing HS (target mean arterial pressure (MAP) 40 mmHg for 30 minutes) were randomised to receive lactated Ringer’s solution (LR group; n =14; volume equal to three times the volume bled), terlipressin (TERLI group; n =14; 2-mg bolus), no treatment (HAEMO group; n =12) or sham (n =6). CPP, systemic haemodynamics (thermodilution technique) and blood gas analyses were registered at baseline, shock and 5, 30, 60 (T60), 90 and 120 minutes after treatment (T120). After the animals were killed, brain tissue samples were obtained to measure markers of water balance (aquaporin-4 (AQP4)), Na+-K+-2Cl− co-transporter (NKCC1)), oxidative stress (thiobarbituric acid reactive substances (TBARS) and manganese superoxide dismutase (MnSOD)) and apoptotic damage (Bcl-x and Bax). Results Despite the HS-induced decrease in cardiac output (CO) and hyperlactataemia, resuscitation with terlipressin recovered MAP and resulted in restoration of CPP and in cerebral protection expressed by normalisation of AQP4, NKCC1, TBARS and MnSOD expression and Bcl-x/Bax ratio at T60 and T120 compared with sham animals. In the LR group, CO and blood lactate levels were recovered, but the CPP and MAP were significantly decreased and TBARS levels and AQP4, NKCC1 and MnSOD expression and Bcl-x/Bax ratio were significantly increased at T60 and T120 compared with the sham group. Conclusions During recovery from HS-induced hypotension, terlipressin was effective in normalising CPP and cerebral markers of water balance, oxidative damage and apoptosis. The role of this pressor agent on brain perfusion in HS requires further investigation.
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Affiliation(s)
- Keila Kazue Ida
- Laboratório de Investigação Médica (LIM-08), Disciplina de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, 2° andar, sala 2120, Cerqueira César, São Paulo, SP, 01246-903, Brazil. .,Department of Neuroinflammation, Institute of Neurology, University College London (UCL), 1 Wakefield Street, 2nd floor, WC1N 1PJ, London, UK.
| | - Denise Aya Otsuki
- Laboratório de Investigação Médica (LIM-08), Disciplina de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, 2° andar, sala 2120, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - Adolfo Toshiro Cotarelli Sasaki
- Laboratório de Investigação Médica (LIM-08), Disciplina de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, 2° andar, sala 2120, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - Emilyn Silva Borges
- Laboratório de Investigação Médica (LIM-08), Disciplina de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, 2° andar, sala 2120, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - Letícia Urbano Cardoso Castro
- Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo (LIM-12 HC-FMUSP), Avenida Doutor Arnaldo, 455, 3rd floor, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - Talita Rojas Sanches
- Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo (LIM-12 HC-FMUSP), Avenida Doutor Arnaldo, 455, 3rd floor, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - Maria-Heloisa Massola Shimizu
- Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo (LIM-12 HC-FMUSP), Avenida Doutor Arnaldo, 455, 3rd floor, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - Lúcia Conceição Andrade
- Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo (LIM-12 HC-FMUSP), Avenida Doutor Arnaldo, 455, 3rd floor, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - José-Otávio Costa Auler
- Laboratório de Investigação Médica (LIM-08), Disciplina de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, 2° andar, sala 2120, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| | - Alex Dyson
- Division of Medicine, University College London (UCL), Gower Street, WC1E 6BT, London, UK.
| | - Kenneth John Smith
- Department of Neuroinflammation, Institute of Neurology, University College London (UCL), 1 Wakefield Street, 2nd floor, WC1N 1PJ, London, UK.
| | - Joel Avancini Rocha Filho
- Divisão de Anestesiologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Av. Dr. Enéas de Carvalho Aguiar,155, 8th floor, 05403-000, São Paulo, SP, Brazil.
| | - Luiz-Marcelo Sá Malbouisson
- Laboratório de Investigação Médica (LIM-08), Disciplina de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, 2° andar, sala 2120, Cerqueira César, São Paulo, SP, 01246-903, Brazil.
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Shahrokhi N, Khaksari M, Soltani Z, Mahmoodi M, Nakhaee N. Effect of sex steroid hormones on brain edema, intracranial pressure, and neurologic outcomes after traumatic brain injury. Can J Physiol Pharmacol 2010; 88:414-21. [PMID: 20555409 DOI: 10.1139/y09-126] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recent studies have reported that estrogen and progesterone have a neuroprotective effect after traumatic brain injury (TBI); however, the mechanism(s) for this effect have not yet been elucidated. The aim of the present study was to investigate the role of sex steroid hormones on changes in brain edema, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) after TBI in ovariectomized (OVX) rats. In this study, 50 female rats were divided into 5 groups: control (intact), sham, and 3 TBI groups consisting of vehicle, estrogen (1 mg/kg), and progesterone (8 mg/kg). TBI was induced by the Marmarou method, and the hormones were injected i.p. 30 min after TBI. ICP was measured in the spinal cord, and CPP was calculated by subtracting the mean arterial pressure (MAP) from ICP. The results revealed that brain water content after TBI was lower (p < 0.001) in the estrogen and progesterone groups than in the vehicle group. After trauma, ICP was significantly higher in TBI rats (p < 0.001). The ICP in the estrogen and progesterone groups decreased at 4 and 24 h after TBI compared with vehicle (p < 0.001 and p < 0.05, respectively). The CPP in the estrogen and progesterone groups increased after 24 h compared with vehicle (p < 0.001). Also after TBI, the neurological score (veterinary coma scale) was significantly higher than vehicle at 1 h (p < 0.01) and 24 h (p < 0.001) in the group treated with estrogen. In conclusion, pharmacological doses of estrogen and progesterone improved ICP, CPP, and neurological scores after TBI in OVX rats, which implies that these hormones play a neuroprotective role in TBI.
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Affiliation(s)
- Nader Shahrokhi
- Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran.
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Rodríguez-Núñez A, Oulego-Erroz I, Gil-Antón J, Pérez-Caballero C, López-Herce J, Gaboli M, Milano G. Continuous Terlipressin Infusion as Rescue Treatment in a Case Series of Children with Refractory Septic Shock. Ann Pharmacother 2010; 44:1545-53. [DOI: 10.1345/aph.1p254] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Despite intensive therapy, refractory pediatric septic shock has a high rate of morbidity and mortality. Additional treatments are needed to improve outcomes in such cases. Objective: To report the clinical effects of continuous terlipressin infusion as rescue treatment for children with septic shock refractory to high catecholamine doses. Methods: Sixteen episodes of catecholamine-resistant septic shock were recorded in 15 children (aged from newborn to 15 years) who received compassionate rescue treatment with terlipressin at 6 pediatric intensive care units. Terlipressin treatment consisted of a loading dose (20 μg/kg) followed by continuous infusion at a rate of 4–20 μg/kg/h. Terlipressin was titrated at increases of 1 μg/kg/h to maintain mean arterial pressure (MAP) in normal range for age and to reduce catecholamine dosage. The main outcome was survival of the episode. Secondary outcomes included hemodynamic effects, ischemia, and terlipressin-related adverse events. Results: Terlipressin increased median MAP from 48 (range 42–63) to 68 (45–115) mm Hg 30 minutes after terlipressin administration (p < 0.01). MAP was subsequently sustained, which allowed for the reduction of norepinephrine infusion from 2 μg/kg/min (1–4) at baseline to 1.5 μg/kg/min (0.4–4) at 1 hour, 1.3 μg/kg/min (0–8) at 4 hours, 1 μg/kg/min (0–2) at 12 hours, 0.45 μg/kg/min (0–1.4) at 24 hours, and 0 μg/kg/min (0–0.6) at 48 hours (p < 0.05 vs baseline in all cases). In 8 (50%) of the 16 septic shock episodes the patients survived, 7 (44%) without sequelae. One patient survived with sequelae (minor amputation and mild cutaneous ischemia). Eight patients had signs of ischemia at admission; terlipressin induced reversible ischemia in another 4 patients. Meningococcal infection, prior ischemia, and MAP were risk factors for mortality. Conclusions: Continuous terlipressin infusion may improve hemodynamics and survival in some children with refractory septic shock. Terlipressin could contribute to tissue ischemia.
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Affiliation(s)
- Antonio Rodríguez-Núñez
- Pediatric Emergency and Critical Care Division, Pediatric Area, Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Javier Gil-Antón
- Pediatric Intensive Care Unit. Hospital de Cruces, Barakaldo, Spain
| | | | - Jesús López-Herce
- Pediatric Intensive Care Service, Hospital General Universitario Gregorio Marañón, Madrid
| | - Mireia Gaboli
- Pediatric Intensive Care Unit, Hospital Clinico Universitario de Salamanca, Salamanca, Spain
| | - Guillermo Milano
- Pediatric Intensive Care Service, Hospital Materno-Infantil, Málaga, Spain
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Saner FH, Canbay A, Gerken G, Broelsch CE. Pharmacology, clinical efficacy and safety of terlipressin in esophageal varices bleeding, septic shock and hepatorenal syndrome. Expert Rev Gastroenterol Hepatol 2007; 1:207-17. [PMID: 19072411 DOI: 10.1586/17474124.1.2.207] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Terlipressin, a vasopressin agonist, is a commonly used drug with different indications, particularly in patients with end-stage liver disease. As a V(1) receptor agonist, it increases systemic vascular resistance, particularly in the splanchnic area, resulting in a decrease of portal pressure. Besides the approved use for variceal bleeding, terlipressin also has beneficial effects in the treatment of hepatorenal syndrome and norepinephrine-resistant septic shock. In patients with cirrhosis and variceal bleeding, the use of terlipressin reduces the portal vein pressure and decreases the pressure in esophageal varices. This can save lives when skilled endoscopists are not immediately available. Hepatorenal syndrome is associated with vasodilation in the mesenteric circulation with arterial underfilling and consecutive renal vasoconstriction. Restoration of an effective arterial blood volume can be achieved by the combination of terlipressin and volume expansion. In some cases, a success rate of up to 75% is reported. The early use of terlipressin in catecholamine-resistant shock can improve organ perfusion.
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Affiliation(s)
- Fuat H Saner
- University Essen, Department of General, Visceral and Transplant Surgery, Hufelandstr. 55, 45122 Essen, Germany.
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