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Bergman ZR, Robbins AJ, Alwan FS, Bellin MD, Kirchner VA, Pruett TL, Mulier KE, Boucher AA, Lusczek ER, Beilman GJ. Perioperative Coagulation Changes in Total Pancreatectomy and Islet Autotransplantation. Pancreas 2022; 51:671-677. [PMID: 36099513 PMCID: PMC9547836 DOI: 10.1097/mpa.0000000000002085] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Thrombotic complications after total pancreatectomy with islet autotransplantation (TPIAT) are common. However, the systemic changes to coagulation in the perioperative period have not been well studied. Our objective was to evaluate the derangements in coagulation in the perioperative period for this procedure. METHODS This was a prospective observational study of patients undergoing elective TPIAT for chronic pancreatitis. Multiple methods of evaluating coagulation, including 2 viscoelastic assays and standard laboratory assays were obtained at defined intraoperative and postoperative intervals. RESULTS Fifteen patients were enrolled. Laboratory values demonstrated initial intraoperative hypercoagulability before significant systemic anticoagulation after islet infusion with heparin. Hypercoagulability is again seen at postoperative days 3 and 7. Subgroup analysis did not identify any major coagulation parameters associated with portal vein thrombosis formation. CONCLUSIONS Apart from the immediate period after islet cell and heparin infusion, patients undergoing TPIAT are generally hypercoagulable leading to a high rate of thrombotic complications. Portal vein thrombosis development had minimal association with systemic derangements in coagulation as it is likely driven by localized inflammation at the time of islet cell infusion. This study may provide the groundwork for future studies to identify improvements in thrombotic complications.
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Affiliation(s)
| | | | | | | | | | | | | | - Alex A Boucher
- Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
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Wolf A, Thakral S, Mulier KE, Suryanarayanan R, Beilman GJ. Evaluation of novel formulations of d-β-hydroxybutyrate and melatonin in a rat model of hemorrhagic shock. Int J Pharm 2018; 548:104-112. [DOI: 10.1016/j.ijpharm.2018.06.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/03/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
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Wolf A, Mulier KE, Muratore SL, Beilman GJ. D-β-Hydroxybutyrate and melatonin for treatment of porcine hemorrhagic shock and injury: a melatonin dose-ranging study. BMC Res Notes 2017; 10:649. [PMID: 29187245 PMCID: PMC5707828 DOI: 10.1186/s13104-017-2975-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/22/2017] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Treatment with a combination of D-β-hydroxybutyrate (BHB) and melatonin (M) improves survival in hemorrhagic shock models. Our objective was to find the most effective melatonin concentration in combination with 4 molar BHB (4 M BHB). Survival and markers of organ injury were analyzed in pigs exposed to pulmonary contusion, liver crush injury, and hemorrhagic shock and treated with lactated Ringer's solution; 4 M BHB/43 mM M; 4 M BHB/20 mM M; 4 M BHB/10 mM M; 4 M BHB/4.3 mM M; or 4 M BHB/0.43 mM M. This work is an extension of a previously published research study. RESULTS Survival was highest in pigs receiving 4 M BHB/43 mM M (13/14), followed by lactated Ringer's solution (11/16) and BHB/M with decreased melatonin concentrations (4 M BHB/20 mM M 3/6, 4 M BHB/10 mM M 2/6, 4 M BHB/4.3 mM M 3/6, 4 M BHB/0.43 mM M 1/6, p = 0.011). High mortality was associated with increases in serum lactate, higher liver and muscle injury markers and decreases in PaO2:FiO2 ratios. Our study indicates that treatment with 4 M BHB and melatonin concentrations below 43 mM lack the survival benefit observed from 4 M BHB/43 mM melatonin in pigs experiencing hemorrhagic shock and polytrauma.
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Affiliation(s)
- Andrea Wolf
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 USA
| | - Kristine E. Mulier
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 USA
| | - Sydne L. Muratore
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 USA
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 USA
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Witowski NE, Lusczek ER, Determan CE, Lexcen DR, Mulier KE, Wolf A, Ostrowski BG, Beilman GJ. Metabolomic analysis of survival in carbohydrate pre-fed pigs subjected to shock and polytrauma. Mol Biosyst 2016; 12:1638-52. [PMID: 26989839 PMCID: PMC5577932 DOI: 10.1039/c5mb00637f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hemorrhagic shock, a result of extensive blood loss, is a dominant factor in battlefield morbidity and mortality. Early rodent studies in hemorrhagic shock reported carbohydrate feeding prior to the induction of hemorrhagic shock decreased mortality. When repeated in our laboratory with a porcine model, carbohydrate pre-feed resulted in a 60% increase in death rate following hemorrhagic shock with trauma when compared to fasted animals (15/32 or 47% vs. 9/32 or 28%). In an attempt to explain the unexpected death rate for pre-fed animals, we further investigated the metabolic profiles of pre-fed non-survivors (n = 15) across 4 compartments (liver, muscle, serum, and urine) at specific time intervals (pre-shock, shock, and resuscitation) and compared them to pre-fed survivors (n = 17). As hypothesized, pre-fed pigs that died as a result of hemorrhage and trauma showed differences in their metabolic and physiologic profiles at all time intervals and in all compartments when compared to pre-fed survivors. Our data suggest that, although all animals were subjected to the same shock and trauma protocol, non-survivors exhibited altered carbohydrate processing as early as the pre-shock sampling point. This was evident in (for example) the higher levels of ATP and markers of greater anabolic activity in the muscle at the pre-shock time point. Based on the metabolic findings, we propose two mechanisms that connect pre-fed status to a higher death rate: (1) animals that die are more susceptible to opening of the mitochondrial permeability transition pore, a major factor in ischemia/reperfusion injury; and (2) loss of fasting-associated survival mechanisms in pre-fed animals.
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Affiliation(s)
- Nancy E Witowski
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | | | | | - Daniel R Lexcen
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Kristine E Mulier
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Andrea Wolf
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | | | - Greg J Beilman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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Wolf A, Mulier KE, Iyegha UP, Asghar JI, Beilman GJ. Safety of D-ß-Hydroxybutyrate and Melatonin for the Treatment of Hemorrhagic Shock With Polytrauma. Shock 2015; 44 Suppl 1:79-89. [DOI: 10.1097/shk.0000000000000315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Pokorney KM, Lexcen DR, Lusczek EER, Determan CE, Witowski NE, Mulier KE, Beilman GJ. Sensitive dependence on initial conditions: metabolism in porcine hemorrhagic shock. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Halámková L, Halámek J, Bocharova V, Wolf S, Mulier KE, Beilman G, Wang J, Katz E. Analysis of biomarkers characteristic of porcine liver injury--from biomolecular logic gates to an animal model. Analyst 2012; 137:1768-70. [PMID: 22407106 DOI: 10.1039/c2an00014h] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A biocatalytic cascade for the analysis of the simultaneous increase in the concentration of two biomarkers characteristic of liver injury (alanine transaminase, ALT, and lactate dehydrogenase, LDH) was tested on real samples acquired from an animal model (domestic pigs, Sus scrofa domesticus) suffering from traumatic liver injury. A two-step reaction biocatalyzed in the presence of both enzyme-biomarkers resulted in the oxidation of NADH followed by optical absorbance measurements. A simple qualitative, YES/NO, test allowed for distinction between animals with and without the presence of liver injury with the probability of 92%. These data represent the first demonstration of applying binary logic systems for the analysis of real biomedical samples.
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Affiliation(s)
- Lenka Halámková
- Department of Chemistry and Biomolecular Science, Clarkson University, Potsdam, NY 13699, USA
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Mulier KE, Lexcen DR, Luzcek E, Greenberg JJ, Beilman GJ. Treatment with beta-hydroxybutyrate and melatonin is associated with improved survival in a porcine model of hemorrhagic shock. Resuscitation 2011; 83:253-8. [PMID: 21864484 DOI: 10.1016/j.resuscitation.2011.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 08/04/2011] [Accepted: 08/05/2011] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The neuroprotective ketone β-hydroxybutyrate (BHB) and the antioxidant melatonin have been found at elevated levels in hibernating mammals. Previous studies in rat models of hemorrhagic shock have suggested a benefit. We compared infusion of 4M BHB and 43 mM melatonin (BHB/M) to 4M sodium chloride and 20% DMSO (control solution) to evaluate for potential benefits in porcine hemorrhagic shock. METHODS Hemorrhagic shock was induced to obtain systolic blood pressures <50 mmHg for 60 min. Pigs were treated with a bolus of either BHB/M (n=9) or control solution (n=8) followed by 4-h infusion of the either BHB/M or control solution. All animals were then resuscitated for 20 h after shock. Physiological data were continually recorded, and blood samples were taken at intervals throughout the experiment. Serum samples were analyzed via high resolution NMR for metabolomic response. RESULTS BHB/M treatment significantly increased 24-h survival time when compared to treatment with control solution (100% versus 62%; p=0.050), with a trend toward decreased volume of resuscitative fluid administered to animals receiving BHB/M. BHB/M-treated animals had lower base deficit and higher oxygen consumption when compared to animals receiving control solution. Serum metabolite profiles revealed increases in β-hydroxybutyrate (BHB), succinate, 2-oxovalerate and adipate with BHB/M treatment as compared with animals treated with control infusion. CONCLUSION Infusion of BHB/M conferred a survival benefit over infusion of control solution in hemorrhagic shock. BHB and its products of metabolism are identified in serum of animals subjected to shock and treated with BHB/M. Further preclinical studies are needed to clarify the mechanisms of action of this promising treatment strategy.
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Affiliation(s)
- Kristine E Mulier
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
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R. Lusczek E, Nelson T, Lexcen D, E. Witowski N, E. Mulier K. Urine Metabolomics in Hemorrhagic Shock: Normalization of Urine in the Face of Changing Intravascular Fluid Volume and Perturbations in Metabolism. ACTA ACUST UNITED AC 2011. [DOI: 10.4172/1948-593x.1000041] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Scribner DM, Witowski NE, Mulier KE, Lusczek ER, Wasiluk KR, Beilman GJ. Liver metabolomic changes identify biochemical pathways in hemorrhagic shock. J Surg Res 2010; 164:e131-9. [PMID: 20855081 DOI: 10.1016/j.jss.2010.07.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 07/06/2010] [Accepted: 07/19/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite ongoing advances in treatment, thousands of patients still die annually from complications due to hemorrhagic shock, a condition causing dramatic physiologic and metabolic changes as cells switch to anaerobic metabolism in response to oxygen deprivation. As the shift from aerobic to anaerobic metabolism occurs in the peripheral tissues during shock, the liver must increase production of endogenous glucose as well as process excess lactate produced in the periphery. This places the liver at the center of metabolic regulation in the body during hemorrhagic shock. Therefore, we hypothesized that liver tissue from pigs during an in vivo model of hemorrhagic shock (n = 6) would reflect resultant metabolic changes. MATERIALS AND METHODS The in vivo model of shock consisted of 45 min of shock followed by 8 h of hypotensive resuscitation (80 mmHg) and subsequent normotensive resuscitation (90 mmHg) ending 48 h after the shock period. Control groups of pigs (n = 3) (1) shock with no resuscitation, and (2) only anesthesia and instrumentation, also were included. Metabolic changes within the liver after shock and during resuscitation were investigated using both proton ((1)H) and phosphorous ((31)P) nuclear magnetic resonance (NMR) spectroscopy. RESULTS Concentrations of glycerylphosphorylcholine (GPC) and glycerylphosphorylethanolamine (GPE) were significantly lower at 8 h after shock, with recovery to baseline by 23 and 48 h after shock. Uridine diphosphate-glucose (UDP-glucose), and phosphoenolpyruvate (PEP) were elevated 23 h after shock. CONCLUSIONS These results indicate that (1)H and (31)P NMR spectroscopy can be used to identify differences in liver metabolites in an in vivo model of hemorrhagic shock, indicating that metabolomic analysis can be used to elucidate biochemical events occurring during this complex disease process.
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Affiliation(s)
- Drew M Scribner
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
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George ME, Beilman GJ, Mulier KE, Myers DE, Wasiluk KR. Noninvasive Tissue Oxygen Saturation Measurements Identify Supply Dependency. J Surg Res 2010; 160:40-6. [DOI: 10.1016/j.jss.2008.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 10/08/2008] [Accepted: 10/14/2008] [Indexed: 10/21/2022]
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Mulier KE, Skarda DE, Taylor JH, Myers DE, McGraw MK, Gallea BL, Beilman GJ. Near-infrared spectroscopy in patients with severe sepsis: correlation with invasive hemodynamic measurements. Surg Infect (Larchmt) 2009; 9:515-9. [PMID: 18687043 DOI: 10.1089/sur.2007.091] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinicians have begun using near-infrared spectroscopy (NIRS) to monitor tissue perfusion in hemorrhagic shock, as the technique allows continuous noninvasive monitoring of tissue hemoglobin oxygen saturation (StO(2)) and the tissue hemoglobin index (THI). We hypothesized that StO(2) measurements in patients with severe sepsis would be associated with the severity of their illness and would correlate with invasive hemodynamic measurements. METHODS We measured mean arterial pressure (MAP), serum lactate concentration, blood hemoglobin concentration, StO(2), and THI in nine healthy volunteers and ten patients with septic shock in a surgical intensive care unit (ICU). Enrolled patients had a pulmonary artery catheter, and had family able to give informed consent. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score at enrollment for the patients was 19 +/- 5 (standard deviation) points. Volunteers and patients were similar with respect to age and sex. To collect NIRS data, we used the InSpectra Tissue Spectrometer, Model 325 (Hutchinson Technology, Inc., Hutchinson, MN). For three consecutive days, we obtained invasive hemodynamic measurements three times daily, simultaneously with NIRS measurements, and metabolic cart measurements once daily. RESULTS Patients with severe sepsis had significantly lower thenar muscle StO(2) values (p = 0.031) than healthy volunteers. Near-infrared spectroscopy-derived mixed venous oxygen saturation (NIRSvO(2)) and StO(2) measured from the thenar eminence in patients with severe sepsis correlated with SvO(2) from the pulmonary artery catheter (p < 0.05). In this group of patients, StO(2) did not correlate significantly with lactate concentration, base deficit, or APACHE II score. CONCLUSIONS Near-infrared spectroscopic measurements of StO(2) correlated with invasive hemodynamic measurements in patients with severe sepsis but did not correlate with severity of illness. These findings suggest that NIRStO(2) may be a clinically useful measurement in monitoring patients with severe sepsis. Further study of this device in early resuscitation of patients with sepsis is necessary.
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Affiliation(s)
- Kristine E Mulier
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Skarda DE, Mulier KE, George ME, Bellman GJ. Eight hours of hypotensive versus normotensive resuscitation in a porcine model of controlled hemorrhagic shock. Acad Emerg Med 2008; 15:845-52. [PMID: 19244635 DOI: 10.1111/j.1553-2712.2008.00202.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [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: 11/30/2022]
Abstract
OBJECTIVES The aim of this study was to compare hypotensive and normotensive resuscitation in a porcine model of hemorrhagic shock. METHODS This was a prospective, comparative, randomized survival study of controlled hemorrhagic shock using 28 male Yorkshire-Landrace pigs (15 to 25 kg). In 24 splenectomized pigs, the authors induced hemorrhagic shock to a systolic blood pressure (sBP) of 48 to 58 mm Hg (approximately 35% bleed). Pigs were randomized to undergo normotensive resuscitation (sBP of 90 mm Hg, n = 7), mild hypotensive resuscitation (sBP of 80 mm Hg, n = 7), severe hypotensive resuscitation (sBP of 65 mm Hg, n = 6), or no resuscitation (n = 4). The authors also included a sham group of animals that were instrumented and splenectomized, but that did not undergo hemorrhagic shock (n = 4). After the initial 8 hours of randomized pressure-targeted resuscitation, all animals were resuscitated to a sBP of 90 mm Hg for 16 hours. RESULTS Animals that underwent severe hypotensive resuscitation were less likely to survive, compared with animals that underwent normotensive resuscitation. Mean arterial pressure (MAP) decreased with hemorrhage and increased appropriately with pressure-targeted resuscitation. Base excess (BE) and tissue oxygen saturation (StO2) decreased in all animals that underwent hemorrhagic shock. This decrease persisted only in animals that were pressure target resuscitated to a sBP of 65 mm Hg. CONCLUSIONS In this model of controlled hemorrhagic shock, initial severe hypotensive pressure-targeted resuscitation for 8 hours was associated with an increased mortality rate and led to a persistent base deficit (BD) and to decreased StO2, suggesting persistent metabolic stress and tissue hypoxia. However, mild hypotensive resuscitation did not lead to a persistent BD or to decreased StO2, suggesting less metabolic stress and less tissue hypoxia.
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Affiliation(s)
- David E Skarda
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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Skarda DE, Putt KS, Hergenrother PJ, Mulier KE, Beilman GJ. Increased poly(ADP-ribose) polymerase activity during porcine hemorrhagic shock is transient and predictive of mortality. Resuscitation 2007; 75:135-44. [PMID: 17467870 DOI: 10.1016/j.resuscitation.2007.02.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2006] [Revised: 02/27/2007] [Accepted: 02/28/2007] [Indexed: 11/20/2022]
Abstract
AIM OF THE STUDY The aim of our study was to compare poly(ADP-ribose) polymerase (PARP) activity levels in a porcine model of hemorrhagic shock and resuscitation. MATERIALS AND METHODS We designed a prospective, comparative randomized survival study of hemorrhagic shock using 20 male Yorkshire-Landrace pigs (15-25 kg). In 16 pigs after splenectomy, we induced hemorrhagic shock to a mean arterial pressure of 50 mm Hg ( approximately 35% bleed). Pigs were randomized to receive normotensive resuscitation (SBP 90 mm Hg), mild hypotensive resuscitation (SBP 80 mm Hg), moderate hypotensive resuscitation (SBP 65 mm Hg), or no resuscitation (n=4 in each group). We also included a group of sham animals that were instrumented and had a splenectomy but not bled (n=4). Muscle and liver biopsies were taken prior to hemorrhage, after 45 min of shock, and 8, 24, and 48 h after resuscitation. PARP activity levels in biopsies were measured using chemical quantitation of NAD+. RESULTS Irrespective of our resuscitation strategy or outcome, both muscle and liver PARP activity levels rose after 45 min of shock and then returned to baseline. Excluding our control animals, PARP activity levels were significantly higher during shock in non-survivors compared to survivors. CONCLUSIONS In our model of porcine hemorrhagic shock, PARP activity levels increased during hemorrhagic shock. However, this increase in PARP activity levels was transient as they returned to baseline regardless of resuscitation strategy. Interestingly, PARP activity levels were significantly higher during hemorrhagic shock in non-survivors compared to survivors. These findings suggest that PARP activity may be a part of initial pathways leading from hemorrhagic shock to death.
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Affiliation(s)
- David E Skarda
- Department of Surgery, University of Minnesota, Minneapolis, MN 55433, USA
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Abstract
This study evaluated near-infrared spectroscopy (NIRS)-derived measurements in hemodynamically stable patients with severe sepsis, as compared with similar measurements in healthy age-matched volunteers. Prospective, preliminary, observational study in a surgical intensive care unit and clinical research center at a university health center. We enrolled 10 patients with severe sepsis and 9 healthy age-matched volunteers. For patients with severe sepsis, we obtained pulmonary artery catheter and laboratory values three times daily for 3 days and oxygen consumption values via metabolic cart once daily for 3 days. For healthy volunteers, we obtained all noninvasive measurements during a single session. We found lower values in patients with severe sepsis (versus healthy volunteers), in tissue oxygen saturation (StO2), in the StO2 recovery slope, in the tissue hemoglobin index, and in the total tissue hemoglobin increase on venous occlusion. Patients with severe sepsis had longer StO2 recovery times and lower NIRS-derived local oxygen consumption values versus healthy volunteers. In our preliminary study, NIRS provides a noninvasive continuous method to evaluate peripheral tissue oxygen metabolism in hemodynamically stable patients with severe sepsis. Further research is needed to demonstrate whether these values apply to broader populations of patients with systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock.
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Affiliation(s)
- David E Skarda
- Department of Surgery, University of Minnesota, Minneapolis, USA
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Skarda DE, Mulier KE, Beilman GJ. Effect of intraabdominal insufflation on hemorrhage from massive blunt liver injury. J Trauma 2006; 61:238-9; author reply 239. [PMID: 16832284 DOI: 10.1097/01.ta.0000222705.05448.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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Abstract
BACKGROUND In field situations, patient triage may require early determination of patients progressing to irreversible shock. We investigated the utility of near-infrared spectroscopy (NIRS) in early detection of irreversible hemorrhagic shock. METHODS Twenty instrumented pigs were treated with a protocol involving 35% blood volume hemorrhage, 90 minutes of shock, and stepwise resuscitation with lactated Ringer's. Hemodynamics and NIRS measurements of skeletal muscle (leg), stomach, and liver tissue oxyhemoglobin saturation (StO2) were measured at baseline, every 30 minutes during shock, and after each resuscitative step. Measurements were compared between animals that expired during resuscitation (unresuscitatable) and animals that survived all resuscitative steps (resuscitatable). RESULTS Neither global oxygen delivery, oxygen consumption, nor lactate distinguished resuscitatable from unresuscitatable animals. Invasive measurements of SvO2 did distinguish resuscitatable from unresuscitatable animals. After the first fluid bolus, both stomach and leg StO2 differed significantly between resuscitatable and unresuscitatable animals. Regression analysis revealed skeletal muscle (leg) StO2 obtained after the first resuscitative step was a significant mortality predictor despite resuscitation (r2=0.45) (p = 0.005). CONCLUSIONS Non-invasive NIRS monitoring of leg and stomach StO2 differentiates resuscitatable from unresuscitatable animals after the initial resuscitative bolus. Use of this non-invasive tool may guide appropriate use of resuscitative fluids and has possible point-of-care applications.
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Affiliation(s)
- Jodie H Taylor
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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Mulier KE, Beilman GJ, Conroy MJ, Taylor JH, Skarda DE, Hammer BE. Ringer's ethyl pyruvate in hemorrhagic shock and resuscitation does not improve early hemodynamics or tissue energetics. Shock 2005; 23:248-52. [PMID: 15718923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Reactive oxygen species (ROS) have been implicated in the pathogenesis of hemorrhagic shock. Ethyl pyruvate, a derivative of pyruvate and a proposed oxygen radical scavenger, is attractive as a possible resuscitation fluid. We investigated whether resuscitation with lactated Ringer's (LR) containing ethyl pyruvate (REP) had any hemodynamic or tissue energetic benefits compared with LR alone for hemorrhagic shock. Hemorrhagic shock was induced in splenectomized pigs via inferior vena cava cannula. After 90 min of shock, animals were resuscitated in a stepwise fashion with LR or REP (30 mg/kg/dose, given as 1.5 mg/mL in LR) at 20 cc/kg/step for four steps. Data collected during this experiment included physiologic and hemodynamic parameters, near-infrared reflectance spectroscopy measurements of tissue hemoglobin oxygen (StO(2)) of the stomach, liver, and hind limb, and nuclear magnetic resonance phosphorus spectra of the liver and hind limb at each time point. In both resuscitative groups, heart rate, and lactate and pyruvate values increased during shock and began to drop toward baseline values during resuscitation. Mean arterial pressure, oxygen delivery, and oxygen consumption decreased during shock and increased toward baseline levels during the resuscitative process. There were no significant changes in physiologic parameters between the LR- and REP-resuscitated animals. There was a significantly lower stomach StO(2) and hind limb cellular cytoplasmic pH during later resuscitative endpoints in REP-resuscitated animals. The clinical significance of these findings are unclear. There is no short-term hemodynamic or tissue energetic advantage to using REP as a resuscitation fluid when compared with LR. Long-term outcome studies are needed to further evaluate any potential benefits of use of REP in hemorrhagic shock.
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Affiliation(s)
- Kristine E Mulier
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Taylor JH, Beilman GJ, Conroy MJ, Mulier KE, Myers D, Gruessner A, Hammer BE. Tissue energetics as measured by nuclear magnetic resonance spectroscopy during hemorrhagic shock. Shock 2004; 21:58-64. [PMID: 14676685 DOI: 10.1097/01.shk.0000101674.49265.93] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The defect in energy production in an organism during shock states may be related to the impairment of mitochondrial respiration early in shock. The aim of this study was to investigate the timing and degree of cellular energetic changes during hemorrhagic shock in real time. Instrumented, splenectomized swine were randomized to undergo hemorrhagic shock, induced by a 35% blood volume bleed, for 90 min with (n = 10) or without (n = 9) subsequent resuscitation. Resuscitated animals received shed blood in two increments followed by two normal saline boluses (20 mL/kg/bolus). Throughout experimentation, tissue phosphoenergetics of liver and skeletal muscle were monitored using 31P nuclear magnetic resonance (NMR) spectroscopy via NMR coils on the liver and hindlimb. Near-infrared spectroscopy probes were used to measure liver, stomach, and skeletal muscle oxyhemoglobin saturation (StO2). Hemorrhagic shock induced an increase in phosphomonoesters in skeletal muscle (baseline: 7.09%, 90 min: 9.94% (P < 0.05); expressed as percent total phosphorus). This increase resolved in animals receiving resuscitation (n = 10) but remained elevated in those in unresuscitated shock (n = 9). Inorganic phosphate levels increased and betaATP levels decreased significantly in the liver of animals in shock as compared with baseline. StO2 in skeletal muscle, stomach, and liver correlated with whole organism oxygen delivery (r2 = 0.356, 0.368, and 0.432, respectively). We conclude that hemorrhagic shock induces early elevation of phosphomonoesters in skeletal muscle, which correlates with the severity of shock. This implies an early transition to anaerobic glycolysis during hemorrhagic shock, which may be indicative of early mitochondrial dysfunction.
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Affiliation(s)
- Jodie H Taylor
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Abstract
BACKGROUND Hemodynamic, laboratory, and tissue energetics were measured in a porcine model of hemorrhagic shock to evaluate variables as predictors of early mortality from shock. We hypothesized that elevated phosphomonoesters would predict early mortality in hemorrhagic shock. METHODS Pigs (n = 36) were subjected to 35% hemorrhage for 90 minutes in a 1.5-T nuclear magnetic resonance (NMR) magnet. Measurements included base deficit (BD); lactate; oxygen consumption/delivery; near-infrared spectroscopy of liver, stomach, and skeletal muscle tissue oxyhemoglobin saturation; and NMR spectroscopic measurements of high-energy phosphates of liver and skeletal muscle. Variables were compared between nonsurvivors and survivors to resuscitation after 90-minute measurements. RESULTS Ninety-minute mortality was 25%. Muscle phosphomonoesters (PMEs) and oxygen consumption differed significantly between survivors and nonsurvivors at baseline. Regression analysis identified baseline muscle PME levels, baseline BD, and 30-minute BD as early predictors of mortality before resuscitation (r2 = 0.304). CONCLUSION Baseline elevation in muscle PME levels predicts mortality in an animal model of severe hemorrhagic shock.
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Affiliation(s)
- Jodie H Taylor
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
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