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Lagazzi E, Wei HS, Panossian VS, Pallotta JB, Calisir A, Rafaqat W, Abiad M, Nzenwa IC, King DR, Hong C, Hammond P, Olsen B, Duggan MJ, Velmahos GC. Development of a two-hit lethal liver injury model in swine. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02546-3. [PMID: 38780780 DOI: 10.1007/s00068-024-02546-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Noncompressible truncal hemorrhage remains a leading cause of preventable death in the prehospital setting. Standardized and reproducible large animal models are essential to test new therapeutic strategies. However, existing injury models vary significantly in consistency and clinical accuracy. This study aims to develop a lethal porcine model to test hemostatic agents targeting noncompressible abdominal hemorrhages. METHODS We developed a two-hit injury model in Yorkshire swine, consisting of a grade IV liver injury combined with hemodilution. The hemodilution was induced by controlled exsanguination of 30% of the total blood volume and a 3:1 resuscitation with crystalloids. Subsequently, a grade IV liver injury was performed by sharp transection of both median lobes of the liver, resulting in major bleeding and severe hypotension. The abdominal incision was closed within 60 s from the injury. The endpoints included mortality, survival time, serum lab values, and blood loss within the abdomen. RESULTS This model was lethal in all animals (5/5), with a mean survival time of 24.4 ± 3.8 min. The standardized liver resection was uniform at 14.4 ± 2.1% of the total liver weight. Following the injury, the MAP dropped by 27 ± 8mmHg within the first 10 min. The use of a mixed injury model (i.e., open injury, closed hemorrhage) was instrumental in creating a standardized injury while allowing for a clinically significant hemorrhage. CONCLUSION This novel highly lethal, consistent, and clinically relevant translational model can be used to test and develop life-saving interventions for massive noncompressible abdominal hemorrhage.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA.
- Department of Surgery, Humanitas Research Hospital, Rozzano, MI, Italy.
| | - Helen S Wei
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Vahe S Panossian
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Jessica B Pallotta
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Anet Calisir
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Ikemsinachi C Nzenwa
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - David R King
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Celestine Hong
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Paula Hammond
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Bradley Olsen
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael J Duggan
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
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McCracken BM, Ward KR, Tiba MH. A review of two emerging technologies for pre-hospital treatment of non-compressible abdominal hemorrhage. Transfusion 2022; 62 Suppl 1:S313-S322. [PMID: 35748670 PMCID: PMC9542827 DOI: 10.1111/trf.16961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Brendan M McCracken
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin R Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Mohamad Hakam Tiba
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Percutaneous delivery of self-propelling hemostatic powder for managing non-compressible abdominal hemorrhage: a proof-of-concept study in swine. Injury 2022; 53:1603-1609. [PMID: 35067343 DOI: 10.1016/j.injury.2022.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/23/2021] [Accepted: 01/12/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Non-compressible intra-abdominal hemorrhage (NCIAH) is a major cause of preventable death on the battlefield and in civilian trauma. Currently, it can only be definitively managed with surgery, as there are limited strategies for controlling ongoing NCIAH in the prehospital environment. We hypothesized that a self-propelling thrombin-containing powder (SPTP) could increase survival in a swine model of NCIAH when delivered percutaneously into the closed abdomen using an engineered spray system. MATERIALS AND METHODS Nineteen swine underwent surgical laparotomy followed by a Grade V liver injury that created massive hemorrhage, before closing the abdomen with sutures. Animals either received treatment with standard of care fluid resuscitation (n=9) or the SPTP spray system (n=10), which consisted of a spray device and a 14 Fr catheter. Using the spray system, SPTP was delivered into a hemoperitoneum identified using a focused assessment with sonography in trauma (FAST) exam. Lactated Ringer's solution was administered to all animals to maintain a mean arterial pressure (MAP) of >50 mmHg. The primary outcome was percentage of animals surviving at three hours following injury. RESULTS In the swine model of NCIAH, a greater percentage of animals receiving SPTP survived to three hours, although differences were not significant. The SPTP spray system increased the median survival of animals from 1.6 hr in the fluid resuscitation group to 4.3 hr. The SPTP spray system delivered a total mass of 18.5 ± 1.0 g of SPTP. The mean change in intra-abdominal pressure following SPTP delivery was 5.2 ± 1.8 mmHg (mean ± SEM). The intervention time was 6.7 ± 1.7 min. No adverse effects related to the SPTP formulation or the spray system were observed. SPTP was especially beneficial in animals that had either severely elevated lactate concentrations or low mean arterial pressure of <35 mmHg shortly after injury. CONCLUSIONS This demonstrates proof-of-concept for use of a new minimally invasive procedure for managing NCIAH, which could extend survival time to enable patients to reach definitive surgical care.
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Naar L, Dorken Gallastegi A, Dowling M, Mashbari HNA, Wallace B, Bankhead-Kendall B, Beagle J, Pallotta JB, Breen K, Velmahos GC, Duggan MJ, King CDR. Chitosan-based lifefoam improves survival in lethal noncompressible abdominal bleeding in swine. Surgery 2022; 172:421-426. [DOI: 10.1016/j.surg.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/19/2021] [Accepted: 01/16/2022] [Indexed: 11/15/2022]
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McCracken BM, Tiba MH, Colmenero CI, Leander DC, Greer NL, Plott JS, Shih AJ, Ward KR. Novel intraperitoneal hemostasis device prolongs survival in a swine model of noncompressible abdominal hemorrhage. J Trauma Acute Care Surg 2021; 90:838-844. [PMID: 33496551 DOI: 10.1097/ta.0000000000003091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Noncompressible torso hemorrhage (NCTH) of the abdomen is a challenge to rapidly control and treat in the prehospital and emergency department settings. In this pilot study, we developed a novel intraperitoneal hemostasis device (IPHD) prototype and evaluated its ability for slowing NCTH and prolonging survival in a porcine model of lethal abdominal multiorgan hemorrhage. METHODS Yorkshire male swine (N = 8) were instrumented under general anesthesia for monitoring of hemodynamics and blood sampling. Animals were subjected to a 30% controlled arterial hemorrhage followed by lacerating combinations of the liver, spleen, and kidney. The abdomen was closed and after 2 minutes of NCTH, and the IPHD was inserted into the peritoneal cavity via an introducer (n = 5). The balloon was inflated and maintained for 60 minutes. At 60 minutes postdeployment, the balloon was deflated and removed, and blood resuscitation was initiated followed by gauze packing for hemostasis. The remaining animals (n = 3) were used as controls and subjected to the same injury without intervention. RESULTS All animals managed with IPHD intervention (5 of 5 swine) survived the duration of the intervention period (60 minutes), while all control animals (3 of 3 swine) died at a time range of 15 to 43 minutes following organ injury (p = 0.0042). Animals receiving IPHD remained hemodynamically stable with a mean arterial pressure range of 44.86 to 55.10 mm Hg and experienced increased cardiac output and decreased shock index after treatment. Controls experienced hemodynamic decline in all parameters until endpoints were met. Upon IPHD deflation and removal, all treated animals began to hemorrhage again and expired within 2 to 132 minutes despite packing. CONCLUSION Our data show that the IPHD concept is capable of prolonging survival by temporarily stanching lethal NCTH of the abdomen. This device may be an effective temporary countermeasure to NCTH of the abdomen that could be deployed in the prehospital environment or as a bridge to more advanced therapy.
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Affiliation(s)
- Brendan M McCracken
- From the Department of Emergency Medicine (B.M.M., M.H.T., C.I.C., D.C.L., N.L.G., K.R.W.), Michigan Center for Integrative Research in Critical Care (B.M.M., M.H.T., C.I.C., D.C.L., N.L.G., J.S.P., A.J.S., K.R.W.), Biomedical Engineering (J.S.P., A.J.S., K.R.W.), and Mechanical Engineering (J.S.P., A.J.S.), University of Michigan, Ann Arbor, Michigan
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