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Neidert LE, Morgan CG, Hathaway EN, Hemond PJ, Tiller MM, Cardin S, Glaser JJ. Effects of hemodilution on coagulation function during prolonged hypotensive resuscitation in a porcine model of severe hemorrhagic shock. Trauma Surg Acute Care Open 2023; 8:e001052. [PMID: 37213865 PMCID: PMC10193089 DOI: 10.1136/tsaco-2022-001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/27/2023] [Indexed: 05/23/2023] Open
Abstract
Background Although hemorrhage remains the leading cause of survivable death in casualties, modern conflicts are becoming more austere limiting available resources to include resuscitation products. With limited resources also comes prolonged evacuation time, leaving suboptimal prehospital field care conditions. When blood products are limited or unavailable, crystalloid becomes the resuscitation fluid of choice. However, there is concern of continuous crystalloid infusion during a prolonged period to achieve hemodynamic stability for a patient. This study evaluates the effect of hemodilution from a 6-hour prehospital hypotensive phase on coagulation in a porcine model of severe hemorrhagic shock. Methods Adult male swine (n=5/group) were randomized into three experimental groups. Non-shock (NS)/normotensive did not undergo injury and were controls. NS/permissive hypotensive (PH) was bled to the PH target of systolic blood pressure (SBP) 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by PH resuscitation with crystalloid for 6 hours. Hemorrhaged animals were then resuscitated with whole blood and recovered. Blood samples were collected at certain time points for analysis of complete blood counts, coagulation function, and inflammation. Results Throughout the 6-hour PFC, hematocrit, hemoglobin, and platelets showed significant decreases over time in the Decomp/PH group, indicating hemodilution, compared with the other groups. However, this was corrected with whole blood resuscitation. Despite the appearance of hemodilution, coagulation and perfusion parameters were not severely compromised. Conclusions Although significant hemodilution occurred, there was minimal impact on coagulation and endothelial function. This suggests that it is possible to maintain the SBP target to preserve perfusion of vital organs at a hemodilution threshold in resource-constrained environments. Future studies should address therapeutics that can mitigate potential hemodilutional effects such as lack of fibrinogen or platelets. Level of evidence Not applicable-Basic Animal Research.
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Affiliation(s)
- Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Emily N Hathaway
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Peter J Hemond
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Michael M Tiller
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Sylvain Cardin
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Jacob J Glaser
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Trauma and Acute Care Surgery, Providence Regional Medical Center Everett, Everett, Washington, USA
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Morgan CG, Neidert LE, Hathaway EN, Tiller MM, Cardin S, Glaser JJ. Cerebral Regional Tissue Oxygenation as Surrogate for Blood Loss in Nonhuman Primate Models of Shock. J Surg Res 2022; 280:186-195. [PMID: 35987168 DOI: 10.1016/j.jss.2022.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/13/2022] [Accepted: 06/29/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Hemorrhage is the leading cause of preventable death, with a majority of mortalities in the prehospital setting. Current hemorrhage resuscitation guidelines cannot predict the critical point of intervention to activate massive transfusion (MT) and prevent cardiovascular decompensation. We hypothesized that cerebral regional tissue oxygenation (CrSO2) would indicate MT need in nonhuman primate models of hemorrhagic shock. METHODS Nineteen anesthetized male rhesus macaques underwent hemorrhage via a volume-targeted (VT) or pressure-targeted (PT) method. VT animals were monitored for 30 min following 30% blood volume hemorrhage. PT animals were hemorrhaged to mean arterial pressure (MAP) of 20 mmHg and maintained for at least 60 min until decompensation. Statistics for MAP, heart rate (HR), end tidal carbon dioxide (EtCO2), and CrSO2 were analyzed via one- or two-way repeated-measures analysis of variance, Pearson's R, and receiver-operator curve. A P < 0.05 is considered significant. RESULTS Following initial hemorrhage (S0), there were no significant differences between groups. After cessation of hemorrhage in the VT group, MAP and EtCO2 returned to baseline while CrSO2 plateaued. The PT group maintained model-defined low MAP, suppressing EtCO2, and significantly decreased CrSO2 compared to the VT group by S25. Linear regression of CrSO2versus shed blood volume demonstrated R2 = 0.7539. CrSO2 of 47% was able to detect >40% blood loss with an area under the curve of 0.9834 at 92.3% (66.7%-99.6%) sensitivity and 95.5% (84.9%-99.2%) specificity. CONCLUSIONS Regardless of hemorrhage modality and compensatory response, CrSO2 correlated strongly with shed blood volume. Analysis demonstrated that CrSO2 values below 49% indicate Advanced Trauma Life Support class IV shock (blood loss>40%). CrSO2 at the point of care may help indicate MT need earlier and more accurately than traditional markers.
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Affiliation(s)
- Clifford G Morgan
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas
| | - Leslie E Neidert
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas
| | | | - Michael M Tiller
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas; Brooke Army Medical Center, JBSA-Ft. Sam Houston, Texas
| | - Sylvain Cardin
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas
| | - Jacob J Glaser
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas; Providence Regional Medical Center, Everett, Washington.
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Stigall KS, Neidert LE, Morgan CG, Hemond PJ, Brown DR, Salas M, Hathaway EN, Tiller MM, Cardin S, Glaser JJ. Therapeutic cardiac arrest as an adjunct to resuscitative endovascular balloon occlusion of the aorta: Bridging the gap from fatal hemorrhage to definitive surgical control in swine. J Trauma Acute Care Surg 2021; 90:369-375. [PMID: 33502148 DOI: 10.1097/ta.0000000000003024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Uncontrolled hemorrhage is the leading cause of potentially survivable combat casualty mortality, with 86.5% of cases resulting from noncompressible torso hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive technique used to stabilize patients with noncompressible torso hemorrhage; however, its application can take an average of 8 minutes to place. One therapeutic capable of bridging this gap is adenosine-lidocaine-magnesium (ALM), which at high doses induces a reversible cardioplegia. We hypothesize by using ALM as an adjunct to REBOA, the ALM-induced cardiac arrest will temporarily halt exsanguination and reduce blood loss, allowing for REBOA placement and control of bleeding. METHODS Male Yorkshire swine (60-80 kg) were randomly assigned to REBOA only or ALM-REBOA (n = 8/group). At baseline, uncontrolled hemorrhage was induced via a 1.5-cm right femoral arteriotomy, and hemorrhaged blood was quantified. One minute after injury (S1), ALM was administered, and 7 minutes later (T0), zone 1 REBOA inflation occurred. If cardiac arrest ensued, cardiac function either recovered spontaneously or advanced life support was initiated. At T30, surgical hemostasis was obtained, and REBOA was deflated. Animals were resuscitated until they were humanely euthanized at T90. RESULTS During field care phase, heart rate and end-tidal CO2 of the ALM-REBOA group were significantly lower than the REBOA only group. While mean arterial pressure significantly decreased from baseline, no significant differences between groups were observed throughout the field care phase. There was no significant difference in survival between the two groups (ALM-REBOA = 89% vs. REBOA only = 100%). Total blood loss was significantly decreased in the ALM-REBOA group (REBOA only = 24.32 ± 1.89 mL/kg vs. ALM-REBOA = 17.75 ± 2.04 mL/kg, p = 0.0499). CONCLUSION Adenosine-lidocaine-magnesium is a novel therapeutic, which, when used with REBOA, can significantly decrease the amount of blood loss at initial presentation, without compromising survival. This study provides proof of concept for ALM and its ability to bridge the gap between patient presentation and REBOA placement.
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Affiliation(s)
- Kyle S Stigall
- From the Department of Surgery, San Antonio Military Medical Center (K.S.S., E.N.H., M.M.T., J.J.G.); Department of Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio (L.E.N., C.G.M., P.J.H., D.R.B., M.S., M.M.T., S.C., J.J.G.), JBSA-Fort Sam Houston; and Austin Shock Trauma (J.J.G.), St David's South Austin Medical Center, Austin, Texas
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Morgan CG, Neidert LE, Hathaway EN, Rodriguez GJ, Schaub LJ, Cardin S, Glaser JJ. Evaluation of prolonged 'Permissive Hypotension': results from a 6-hour hemorrhage protocol in swine. Trauma Surg Acute Care Open 2019; 4:e000369. [PMID: 31803845 PMCID: PMC6887504 DOI: 10.1136/tsaco-2019-000369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/11/2019] [Accepted: 10/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background Tactical Combat Casualty Care guidelines for hemorrhage recommend resuscitation to systolic blood pressure (SBP) of 85±5 mm Hg during prehospital care. Success depends on transport to definitive care within the ‘golden hour’. As future conflicts may demand longer prehospital/transport times, we sought to determine safety of prolonged permissive hypotension (PH). Methods Adult male swine were randomized into three experimental groups. Non-shock (NS)/normotensive underwent anesthesia only. NS/PH was bled to SBP of 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by 6 hours of PFC. Hemorrhaged animals were then resuscitated with whole blood and observed for 24 hours. Physiologic variables, blood, tissue samples, and neurologic scores were collected. Results Survival of all groups was 100%. Fluid volumes to maintain targeted SBP in PFC were significantly higher in the hemorrhage group than sham groups. After 24 hours’ recovery, no significant differences were observed in neurologic scores or cerebrospinal fluid markers of brain injury. No significant changes in organ function related to treatment were observed during PFC through recovery, as assessed by serum chemistry and histological analysis. Conclusions After 6 hours, a prolonged PH strategy showed no detrimental effect on survival or neurologic outcome despite the increased ischemic burden of hemorrhage. Significant fluid volume was required to maintain SBP—a potential logistic burden for prehospital care. Further work to define maximum allowable time of PH is needed. Study type Translational animal model. Level of evidence N/A.
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Affiliation(s)
- Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Emily N Hathaway
- Division of Trauma Critical Care, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Gerardo J Rodriguez
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Leasha J Schaub
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Sylvain Cardin
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Jacob J Glaser
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA.,Division of Trauma Critical Care, San Antonio Military Medical Center, San Antonio, Texas, USA
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Abstract
Three monkeys performed a visually guided reach-touch task with and without laterally displacing prisms. The prisms offset the normally aligned gaze/reach and subsequent touch. Naive monkeys showed adaptation, such that on repeated prism trials the gaze-reach angle widened and touches hit nearer the target. On the first subsequent no-prism trial the monkeys exhibited an aftereffect, such that the widened gaze-reach angle persisted and touches missed the target in the direction opposite that of initial prism-induced error. After 20-30 days of training, monkeys showed long-term learning and storage of the prism gaze-reach calibration: they switched between prism and no-prism and touched the target on the first trials without adaptation or aftereffect. Injections of lidocaine into posterolateral cerebellar cortex or muscimol or lidocaine into dentate nucleus temporarily inactivated these structures. Immediately after injections into cortex or dentate, reaches were displaced in the direction of prism-displaced gaze, but no-prism reaches were relatively unimpaired. There was little or no adaptation on the day of injection. On days after injection, there was no adaptation and both prism and no-prism reaches were horizontally, and often vertically, displaced. A single permanent lesion (kainic acid) in the lateral dentate nucleus of one monkey immediately impaired only the learned prism gaze-reach calibration and in subsequent days disrupted both learning and performance. This effect persisted for the 18 days of observation, with little or no adaptation.
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Affiliation(s)
- Scott A Norris
- Department of Neurology, Washington University School of Medicine, Box 8111, 660 S. Euclid Ave., St. Louis, MO 63110, USA.
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Norris SA, Greger B, Hathaway EN, Thach WT. Purkinje Cell Spike Firing in the Posterolateral Cerebellum: Correlation With Visual Stimulus, Oculomotor Response, and Error Feedback. J Neurophysiol 2004; 92:1867-79. [PMID: 15128755 DOI: 10.1152/jn.01251.2003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Complex (CS)- and simple-spike (SS) discharge from single Purkinje cells (Pc) in the posterolateral cerebellum of two monkeys was recorded during a visually guided reach-touch task. A visual target appeared (TA) off-gaze at a random location on a screen. On initiation of arm reach, the target disappeared, then reappeared (TR) after a fixed delay. TR was either at the same location (baseline condition) or a shifted location at a fixed distance and direction from TA location (shift condition). Across trials, we observed one or two peaks of CS activity, depending on the reach condition. The first CS (T1 CS) peak was tuned to the location of TA on the screen, following TA by ∼150 ms. The second CS (T2 CS) peak occurred only in the shift condition, was tuned to the shift location of TR, and followed TR by ∼150 ms. The locational preferences of T1 and T2 CS peaks were the same. T1 and T2 CSs preceded saccades to TA and TR at the preferred location and occurred during reaches with either arm. T1 CSs occurred during trials in which the target appeared, and there was a saccade to target, but no subsequent arm reach followed. SS firing varied with TA/TR in the same preferred location as for the accompanying CS. We conclude that posterolateral Pc CS and SS firing changes following an off-gaze visual target appearance in a preferred location when there is a subsequent saccade to that location.
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Affiliation(s)
- Scott A Norris
- Dept. of Anatomy and Neurobiology, Washington University School of Medicine, Campus Box 8108, 660 S. Euclid Ave., St. Louis, MO 63110, USA
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