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1.
Adv Exp Med Biol ; 1269: 283-288, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33966231

RESUMO

Hemorrhagic shock (HS) is a severe complication of traumatic brain injury (TBI) that doubles mortality due to severely compromised microvascular cerebral blood flow (mvCBF) and oxygen delivery reduction, as a result of hypotension. Volume expansion with resuscitation fluids (RF) for HS does not improve microvascular CBF (mvCBF); moreover, it aggravates brain edema. We showed that the addition of drag-reducing polymers (DRP) to crystalloid RF (lactated Ringer's) significantly improves mvCBF, oxygen supply, and neuronal survival in rats suffering TBI+HS. Here, we compared the effects of colloid RF (Hetastarch) with DRP (HES-DRP) and without (HES). Fluid percussion TBI (1.5 ATA, 50 ms) was induced in rats and followed by controlled HS to a mean arterial pressure (MAP) of 40 mmHg. HES or HES-DRP was infused to restore MAP to 60 mmHg for 1 h (prehospital period), followed by blood reinfusion to a MAP of 70 mmHg (hospital period). In vivo two-photon microscopy was used to monitor cerebral microvascular blood flow, tissue hypoxia (NADH), and neuronal necrosis (i.v. propidium iodide) for 5 h after TBI+HS, followed by postmortem DiI vascular painting. Temperature, MAP, blood gases, and electrolytes were monitored. Statistical analyses were done using GraphPad Prism by Student's t-test or Kolmogorov-Smirnov test, where appropriate. TBI+HS compromised mvCBF and tissue oxygen supply due to capillary microthrombosis. HES-DRP improved mvCBF and tissue oxygenation (p < 0.05) better than HES. The number of dead neurons in the HES-DRP was significantly less than in the HES group: 76.1 ± 8.9 vs. 178.5 ± 10.3 per 0.075 mm3 (P < 0.05). Postmortem visualization of painted vessels revealed vast microthrombosis in both hemispheres that were 33 ± 2% less in HES-DRP vs. HES (p < 0.05). Thus, resuscitation after TBI+HS using HES-DRP effectively restores mvCBF and reduces hypoxia, microthrombosis, and neuronal necrosis compared to HES. HES-DRP is more neuroprotective than lactated Ringer's with DRP and requires an infusion of a smaller volume, which reduces the development of hypervolemia-induced brain edema.


Assuntos
Lesões Encefálicas Traumáticas , Choque Hemorrágico , Animais , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/terapia , Coloides , Microcirculação , Polímeros , Ratos , Ratos Sprague-Dawley , Ressuscitação , Choque Hemorrágico/terapia
2.
J Spec Oper Med ; 21(1): 30-36, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33721303

RESUMO

BACKGROUND: Two methods of controlling pelvic and inguinal hemorrhage are the Abdominal Aortic and Junctional Tourniquet (AAJT; Compression Works) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT can be applied quickly, but prolonged use may damage the bowel, inhibit ventilation, and obstruct surgical access. REBOA requires technical proficiency but avoids many of the complications associated with the AAJT. Conversion of the AAJT to REBOA would allow for field hemorrhage control with mitigation of the morbidity associated with prolonged AAJT use. METHODS: Yorkshire male swine (n = 17; 70-90kg) underwent controlled 40% hemorrhage. Subsequently, AAJT was placed on the abdomen, midline, 2cm superior to the ilium, and inflated. After 1 hour, the animals were allocated to an additional 30 minutes of AAJT inflation (continuous AAJT occlusion [CAO]), REBOA placement with the AAJT inflated (overlapping aortic occlusion [OAO]), or REBOA placement following AAJT removal (sequential aortic occlusion [SAO]). Following removal, animals were observed for 3.5 hours. RESULTS: No statistically significant differences in survival, blood pressure, or laboratory values were found following intervention. Conversion to REBOA was successful in all animals but one in the OAO group. REBOA placement time was 4.3 ± 2.9 minutes for OAO and 4.1 ± 1.8 minutes for SAO (p = .909). No animal had observable intestinal injury. CONCLUSIONS: Conversion of the AAJT to infrarenal REBOA is practical and effective, but access may be difficult while the AAJT is applied.


Assuntos
Oclusão com Balão , Procedimentos Endovasculares , Choque Hemorrágico , Animais , Aorta Abdominal , Hemorragia/terapia , Masculino , Ressuscitação , Choque Hemorrágico/terapia , Suínos , Torniquetes
3.
Medicine (Baltimore) ; 100(12): e25143, 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33761680

RESUMO

BACKGROUND: Whether to use limited fluid resuscitation (LFR) in patients with hemorrhagic shock or septic shock remains controversial. This research was aimed to assess the pros and cons of utilizing LFR in hemorrhagic shock or septic shock patients. METHODS: PubMed, Cochrane Library, Embase, Web of science, CNKI, VIP, and Wan Fang database searches included for articles published before December 15, 2020. Randomized controlled trials of LFR or adequate fluid resuscitation in hemorrhagic shock or septic shock patients were selected. RESULT: This meta-analysis including 28 randomized controlled trials (RCTs) and registered 3288 patients. The 7 of 27 RCTs were the patients with septic shock. Others were traumatic hemorrhagic shock patients. Comparing LFR or adequate fluid resuscitation in hemorrhagic shock or septic shock patients, the summary odds ratio (OR) was 0.50 (95% confidence interval [CI] 0.42-0.60, P < .00001) for mortality, 0.46 (95% CI 0.31-0.70, P = .0002) for multiple organ dysfunction syndrome (MODS), 0.35 (95% CI 0.25-0.47) for acute respiratory distress syndrome (ARDS), and 0.33 (95% CI 0.20-0.56) for disseminated intravascular coagulation (DIC). CONCLUSION: Limited fluid resuscitation is the benefit of both traumatic hemorrhagic shock patients and septic shock patients.


Assuntos
Hidratação/mortalidade , Ressuscitação/mortalidade , Choque Hemorrágico/terapia , Choque Séptico/terapia , Choque Traumático/terapia , Hidratação/métodos , Humanos , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto , /mortalidade , Ressuscitação/métodos , Choque Hemorrágico/complicações , Choque Hemorrágico/mortalidade , Choque Séptico/complicações , Choque Séptico/mortalidade , Choque Traumático/complicações , Choque Traumático/mortalidade , Resultado do Tratamento
5.
J Trauma Acute Care Surg ; 90(4): 615-622, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33405469

RESUMO

BACKGROUND: Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) attempts to minimize ischemia/reperfusion injury while controlling hemorrhage. There are little data on optimal methods to evaluate and titrate partial flow, which typically requires invasive arterial line monitoring. We sought to examine the use of a miniaturized handheld digital pressure device (COMPASS; Mirador Biomedical, Seattle, WA) for pREBOA placement and titration of flow. METHODS: Ten swine underwent standardized hemorrhagic shock. Carotid and iliac pressures were monitored with both arterial line and COMPASS devices, and flow was monitored by aortic and superior mesenteric artery flow probes. Partial resuscitative endovascular balloon occlusion of the aorta was inflated to control hemorrhage for 15 minutes before being deflated to try targeting aortic flow of 0.7 L/min (using only the COMPASS device) by an operator blinded to the arterial line pressures and aortic flow. Correlations between COMPASS and proximal/distal arterial line were evaluated, as well as actual aortic flow. RESULTS: There was strong correlation between the distal mean arterial pressure (MAP) and the distal COMPASS MAP (r = 0.979, p < 0.01), as well as between the proximal arterial line and the proximal COMPASS on the pREBOA (r = 0.989, p < 0.01). There was a significant but weaker correlation between the distal compass MAP reading and aortic flow (r = 0.47, p < 0.0001), although it was not clinically significant and predicted flow was not achieved in a majority of the procedures. Of 10 pigs, survival times ranged from 10 to 120 minutes, with a mean survival of 50 minutes, and 1 pig surviving to 120 minutes. CONCLUSION: Highly reliable pressure monitoring is achieved proximally and distally without arterial lines using the COMPASS device on the pREBOA. Despite accurate readings, distal MAPs were a poor indicator of aortic flow, and titration based upon distal MAPs did not provide reliable results. Further investigation will be required to find a suitable proxy for targeting specific aortic flow levels using pREBOA.


Assuntos
Oclusão com Balão , Monitores de Pressão Arterial , Procedimentos Endovasculares , Sistemas Automatizados de Assistência Junto ao Leito , Choque Hemorrágico/fisiopatologia , Choque Hemorrágico/terapia , Animais , Aorta/fisiopatologia , Pressão Arterial , Modelos Animais de Doenças , Masculino , Traumatismo por Reperfusão/prevenção & controle , Reprodutibilidade dos Testes , Ressuscitação , Suínos
8.
J Trauma Acute Care Surg ; 90(3): 426-433, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33492106

RESUMO

BACKGROUND: Hemorrhage is a leading cause of mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) can control hemorrhage, but distal ischemia, subsequent reperfusion injury, and the need for frequent balloon titration remain problems. Improved device design can allow for partial REBOA (pREBOA) that may provide hemorrhage control while also perfusing distally without need for significant provider titration. METHODS: Female Yorkshire swine (N = 10) were subjected to 40% hemorrhagic shock for 1 hour (mean arterial pressure [MAP], 28-32 mm Hg). Animals were then randomized to either complete aortic occlusion (ER-REBOA) or partial occlusion (novel pREBOA-PRO) without frequent provider titration or distal MAP targets. Detection of a trace distal waveform determined partial occlusion in the pREBOA-PRO arm. After 2 hours of zone 1 occlusion, the hemorrhaged whole blood was returned. After 50% autotransfusion, the balloon was deflated over a 10-minute period. Following transfusion, the animals were survived for 2 hours while receiving resuscitation based on objective targets: lactated Ringer's fluid boluses (goal central venous pressure, ≥ 6 mm Hg), a norepinephrine infusion (goal MAP, 55-60 mm Hg), and acid-base correction (goal pH, >7.2). Hemodynamic variables, arterial lactate, lactate dehydrogenase, aspartate aminotransferase, and creatinine levels were measured. RESULTS: All animals survived throughout the experiment, with similar increase in proximal MAPs in both groups. Animals that underwent partial occlusion had slightly higher distal MAPs. At the end of the experiment, the partial occlusion group had lower end levels of serum lactate (p = 0.006), lactate dehydrogenase (p = 0.0004) and aspartate aminotransferase (p = 0.004). Animals that underwent partial occlusion required less norepinephrine (p = 0.002), less bicarbonate administration (p = 0.006), and less fluid resuscitation (p = 0.042). CONCLUSION: Improved design for pREBOA can decrease the degree of distal ischemia and reperfusion injury compared with complete aortic occlusion, while providing a similar increase in proximal MAPs. This can allow pREBOA zone-1 deployment for longer periods without the need for significant balloon titration.


Assuntos
Aorta , Oclusão com Balão/instrumentação , Procedimentos Endovasculares/instrumentação , Traumatismo por Reperfusão/prevenção & controle , Ressuscitação/instrumentação , Choque Hemorrágico/terapia , Animais , Pressão Arterial , Oclusão com Balão/efeitos adversos , Oclusão com Balão/métodos , Modelos Animais de Doenças , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Traumatismo por Reperfusão/etiologia , Ressuscitação/efeitos adversos , Ressuscitação/métodos , Suínos
9.
Rev Med Liege ; 75(10): 649-652, 2020 Oct.
Artigo em Francês | MEDLINE | ID: mdl-33030840

RESUMO

Transfusion plays a major role in the management of hemorrhagic shock where every minute counts. A pre-hospital transfusion protocol is established in the medical vehicle within the emergency department of CHR hospital Liège. It is based on predefined clinical and biological severity criteria which allow us to start a massive transfusion protocol as early as possible and thus to optimize its effect during traumatic hemorrhagic shock.


Assuntos
Transfusão de Sangue , Choque Hemorrágico , Serviço Hospitalar de Emergência , Hemorragia , Humanos , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia
10.
Annu Int Conf IEEE Eng Med Biol Soc ; 2020: 4978-4981, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-33019104

RESUMO

We investigated whether a statistical model could predict mean arterial pressure (MAP) during uncontrolled hemorrhage; such a model could be used for automated decision support, to help clinicians decide when to provide intravascular volume to achieve MAP goals. This was a secondary analysis of adult swine subjects during uncontrolled splenic bleeding. By protocol, after developing severe hypotension (MAP < 60 mmHg), subjects were resuscitated with either saline (NS) or fresh frozen plasma (FFP), determined randomly. Vital signs were documented at quasi-regular time-step intervals, until either subject death or 300 min. Subjects were randomly separated 50%/50% into training/validation sets, and regression models were developed to predict MAP for each subsequent (i.e., future) time-step. Median time-steps for serially recorded vital signs were +15 min. 5 subjects survived the protocol; 17 died after a median time of 87 min (IQR 78 - 134). The final model consisted of: current MAP; heart rate (HR); prior NS; imminent NS; and imminent FFP. The 95% limits-of-agreement between true subsequent MAP vs. predicted subsequent MAP were +10/-11 mmHg for the 79 time-steps in the training set; and +14/-13 for the 64 time-steps in the validation set. A total of 10 sudden death events (i.e., rapid, fatal MAP decrease within one single time-step) were excluded from analysis. In conclusion, for uncontrolled hemorrhage in a swine model, it was possible to estimate the next documented MAP value on the basis of the subject's current documented MAP; HR; prior NS; and the volume of resuscitation about to be administered. However, the model was unable to predict "sudden death" events. The applicability to populations with wider heterogeneity of hemorrhage patterns and with comorbidities requires further investigation.


Assuntos
Choque Hemorrágico , Animais , Modelos Animais de Doenças , Hemodinâmica , Hemorragia/terapia , Ressuscitação , Choque Hemorrágico/terapia , Suínos
11.
J Spec Oper Med ; 20(3): 97-102, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32969011

RESUMO

Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.


Assuntos
Choque Hemorrágico , Humanos , Consumo de Oxigênio , Respiração com Pressão Positiva/efeitos adversos , Indução e Intubação de Sequência Rápida , Ressuscitação , Choque Hemorrágico/etiologia , Choque Hemorrágico/terapia
12.
J Spec Oper Med ; 20(3): 128-134, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32969018

RESUMO

Future expeditionary missions are expected to occur in more remote austere environments where combat medics and casualties may have to wait up to 7 days before resupply or safe evacuation. Currently, there is no effective fluid therapy for hemorrhagic shock (HS) at the point-of-injury and continuum-of-care over this extended period. We have been developing a small-volume IV or IO ALM therapy for noncompressible HS and have shown in preclinical models that it extends survival to 3 days, reduces abdominal bleeding by 60%, blunts inflammation, corrects coagulopathy, preserves platelet function, and prevents immunodeficiency. The ALM-survival phenotype is associated with an upregulation of the master genes of metabolism and mitochrondrial biogenesis in heart and brain and a downregulation in the periphery. Future translational studies will investigate the timing and nature of the "switch" and extend survival to 7 days. We will also discuss some of the controversies of ALM resuscitation in pigs, present our Systems Hypothesis of Trauma (SHOT), and discuss future clinical safety trials before field use.


Assuntos
Choque Hemorrágico , Adenosina/uso terapêutico , Animais , Hidratação , Lidocaína/uso terapêutico , Magnésio/uso terapêutico , Ressuscitação , Choque Hemorrágico/terapia , Suínos
13.
Emerg Med Clin North Am ; 38(4): 795-805, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981618

RESUMO

Successful emergency transfusions require early recognition and activation of resources to minimize treatment delays. The initial goals should focus on replacement of blood in a balanced fashion. There is an ongoing debate regarding the best approach to transfusions, with some advocating for resuscitation with a fixed ratio of blood products and others preferring to use viscoelastic assays to guide transfusions. Whole-blood transfusion also is a debated strategy. Despite these different approaches, it generally is accepted that transfusions should be started early and crystalloid infusions limited. As hemodynamic stability is restored, endpoints of resuscitation should be used to guide the resuscitation.


Assuntos
Transfusão de Sangue , Choque Hemorrágico/terapia , Antifibrinolíticos/uso terapêutico , Tipagem e Reações Cruzadas Sanguíneas , Cateterismo Venoso Central , Tomada de Decisão Clínica , Protocolos Clínicos , Estado Terminal , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Humanos , Hipotensão , Infusões Intraósseas , Infusões Intravenosas , Ressuscitação , Tromboelastografia , Ácido Tranexâmico/uso terapêutico , Ferimentos e Lesões/terapia
14.
Einstein (Sao Paulo) ; 18: eAO5032, 2020.
Artigo em Português, Inglês | MEDLINE | ID: mdl-32876090

RESUMO

Objective To describe the implementation of a care protocol based on rapid response teams, for management and resolution of bleeding. Methods A hospital protocol called Hemorrhage Code (Code H) was devised and developed. In a flow line, a multidisciplinary team provides comprehensive, fast and effective care to the patient with a severe hemorrhagic condition. In another flow line, professionals based at the hospital pharmacy focus on identifying patients at risk of bleeding, to avoid this event. Several hospital professionals and sectors were trained, each with specific roles, ensuring full support to the medical and nursing staffs. Results After implementing this protocol, we were able to significantly reduce the number of catastrophic events related to failure in bleeding management. Conclusion Code H is an example of a value-based medicine and precision medicine project by delivering comprehensive and multidisciplinary care, in addition to point-of-care testing introduced in clinical practice, optimizing patient safety and care practices at the hospital. Furthermore, it will be possible to minimize the risk of lawsuits for the hospital and physicians, as well as rationalizing resources with benefits for administrators and payers.


Assuntos
Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue , Hemorragia/terapia , Assistência ao Paciente/normas , Segurança do Paciente , Guias de Prática Clínica como Assunto , Choque Hemorrágico/terapia , Brasil , Hemorragia/prevenção & controle , Humanos , Estudos Retrospectivos
15.
J Trauma Acute Care Surg ; 89(2): 329-335, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32744830

RESUMO

INTRODUCTION: Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS: We analyzed the (2015-2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1-1]; pRBC, 16 [10-23]; FFP, 9 [6-16]; platelets, 3 [2-5]) and 8,214 received CT only (pRBC, 15 [10-24]; FFP, 10 [6-16]; platelets, 2 [1-4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24-43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7-12] vs. 15 [10-21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59-0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81-0.90]; p = 0.011), and major complications (OR, 0.92 [0.87-0.96]; p = 0.013). CONCLUSION: The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Transfusão de Componentes Sanguíneos , Transfusão de Sangue , Técnicas Hemostáticas , Choque Hemorrágico/terapia , Ferimentos e Lesões/complicações , Adulto , Terapia Combinada , Serviço Hospitalar de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/etiologia , Resultado do Tratamento , Estados Unidos
16.
Am J Nurs ; 120(9): 36-43, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32858696

RESUMO

Optimal management of trauma-related hemorrhagic shock begins at the point of injury and continues throughout all hospital settings. Several procedures developed on the battlefield to treat this condition have been adopted by civilian health care systems and are now used in a number of nonmilitary hospitals. Despite the important role nurses play in caring for patients with trauma-related hemorrhagic shock, much of the literature on this condition is directed toward paramedics and physicians. This article discusses the general principles underlying the pathophysiology and clinical management of trauma-related hemorrhagic shock and updates readers on nursing practices used in its management.


Assuntos
Serviços Médicos de Emergência/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Choque Hemorrágico/terapia , Centros de Traumatologia/organização & administração , Hemorragia/terapia , Hemostáticos/uso terapêutico , Humanos , Traumatismo Múltiplo/complicações , Choque Hemorrágico/enfermagem , Gestão da Qualidade Total
17.
PLoS One ; 15(7): e0235084, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32614837

RESUMO

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.


Assuntos
Hemodinâmica/efeitos dos fármacos , Solução Salina/uso terapêutico , Choque Hemorrágico/terapia , Terlipressina/uso terapêutico , Vasoconstritores/uso terapêutico , Animais , Animais Recém-Nascidos , Circulação Cerebrovascular/efeitos dos fármacos , Modelos Animais de Doenças , Hidratação , Masculino , Ressuscitação , Choque Hemorrágico/sangue , Choque Hemorrágico/fisiopatologia , Suínos
18.
Surgery ; 168(4): 690-694, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32660865

RESUMO

BACKGROUND: The elevated shock index, pediatric age-adjusted (SIPA) has been found to accurately predict the need for blood transfusion in severely injured children. We sought to determine the utility of monitoring sequential SIPA values from the prehospital setting through the emergency department to identify children with a blunt liver or spleen injury who will require a blood transfusion. METHODS: We conducted a retrospective review of children 1 to 18 years old admitted to a level-1 pediatric trauma center with any grade blunt liver or spleen injury between 2009 and 2019. Cohorts were stratified into those who received a blood transfusion within the first 24 hours after injury and those who did not. RESULTS: A total of 477 children had a blunt liver or spleen injury during the study period, of which 20% (95 of 477) received a blood transfusion within 24 hours of trauma center arrival. Of those who received a blood transfusion, 75% (71 of 95) were transfused within 6 hours of arrival at our center. Nearly 90% (84 of 95) of patients who received blood had at least 1 elevated SIPA score in either setting (prehospital or emergency department). Based on multivariable regression, an elevated SIPA score in either setting was significantly associated with blood transfusion (odds ratio 7.8 (confidence interval 4.7-12.9, P = .002). CONCLUSION: Elevated SIPA values in the prehospital setting and on emergency department arrival are associated with early blood transfusion. The importance of this finding is that after serial SIPA values may assist in the early identification of children with blunt liver or spleen injury who will require a blood transfusion.


Assuntos
Transfusão de Sangue , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Fígado/lesões , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/terapia , Baço/lesões , Ferimentos não Penetrantes/complicações , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Escala de Gravidade do Ferimento , Estudos Retrospectivos , Resultado do Tratamento , Triagem
19.
J Surg Res ; 254: 390-397, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32540506

RESUMO

BACKGROUND: Noncompressible torso hemorrhage remains a leading cause of death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) placement may occur before transport; however, its efficacy has not been demonstrated at altitude. We hypothesized that changes in altitude would not result in blood pressure changes proximal to a deployed REBOA. METHODS: A simulation model for 7Fr guidewireless REBOA was used at altitudes up to 22,000 feet. Female pigs then underwent hemorrhagic shock to a mean arterial pressure (MAP) of 40 mm Hg. After hemorrhage, a REBOA catheter was deployed in the REBOA group and positioned but not inflated in the no-REBOA group. Animals underwent simulated aeromedical evacuation at 8000 ft or were left at ground level. After altitude exposure, the balloon was deflated, and the animals were observed. RESULTS: Taking the REBOA catheter to 22,000 ft in the simulation model resulted in a lower systolic blood pressure but a preserved MAP. In the porcine model, REBOA increased both systolic blood pressure and MAP compared with no-REBOA (P < 0.05) and was unaffected by altitude. No differences in postflight blood pressure, acidosis, or systemic inflammatory response were observed between ground and altitude REBOA groups. CONCLUSIONS: REBOA maintained MAP up to 22,000 feet in an inanimate model. In the porcine model, REBOA deployment improved MAP, and the balloon remained effective at altitude.


Assuntos
Medicina Aeroespacial , Altitude , Aorta , Oclusão com Balão , Choque Hemorrágico/terapia , Animais , Pressão Sanguínea , Procedimentos Endovasculares , Feminino , Distribuição Aleatória , Suínos
20.
J Trauma Acute Care Surg ; 89(1): 58-67, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32569103

RESUMO

OBJECTIVES: Partial restoration of aortic flow during resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated by some to mitigate distal ischemia. Our laboratory has validated the mechanics and optimal partial REBOA (pREBOA) flow rates using a prototype device. We hypothesize that pREBOA will increase survival when compared with full REBOA (fREBOA) in prolonged nonoperative management of hemorrhagic shock. METHODS: Twenty swine underwent placement of aortic flow probes, zone 1 REBOA placement, and 20% blood volume hemorrhage. They were randomized to either solid organ or abdominal vascular injury. The pREBOA arm (10 swine) underwent full inflation for 10 minutes and then deflation to a flow rate of 0.5 L/min for 2 hours. The fREBOA arm (10 swine) underwent full inflation for 60 minutes, followed by deflation/resuscitation. The primary outcome is survival, and secondary outcomes are serologic/pathologic signs of ischemia-reperfusion injury and quantity of hemorrhage. RESULTS: Two of 10 swine survived in the fREBOA group (2/5 solid organ injury; 0/5 abdominal vascular injury), whereas 7 of 10 swine survived in the pREBOA group (3/5 solid organ injury, 4/5 abdominal vascular injury). Survival was increased (p = 0.03) and hemorrhage was higher in the pREBOA group (solid organ injury, 1.36 ± 0.25 kg vs. 0.70 ± 0.33 kg, p = 0.007; 0.86 ± 0.22 kg vs. 0.71 ± 0.28 kg, not significant). Serum evidence of ischemia was greater with fREBOA, but this was not significant (e.g., lactate, 16.91 ± 3.87 mg/dL vs. 12.96 ± 2.48 mg/dL at 120 minutes, not significant). Swine treated with pREBOA that survived demonstrated trends toward lower alanine aminotransferase, lower potassium, and higher calcium. The potassium was significantly lower in survivors at 60 minutes and 90 minutes time points (5.97 ± 0.60 vs. 7.53 ± 0.90, p = 0.011; 6.67 ± 0.66 vs. 8.15 ± 0.78, p = 0.029). Calcium was significantly higher at 30 minutes, 60 minutes, and 90 minutes (8.56 ± 0.66 vs. 7.50 ± 0.40, p = 0.034; 8.63 ± 0.62 vs. 7.15 ± 0.49, p = 0.019; 8.96 ± 0.64 vs. 7.00, p = 0.028). CONCLUSION: Prolonged pREBOA at a moderate distal flow rate provided adequate hemorrhage control, improved survival, and had evidence of decreased ischemic injury versus fREBOA. Prophylactic aggressive calcium supplementation may have utility before and during the reperfusion phase.


Assuntos
Aorta , Oclusão com Balão/instrumentação , Fígado/lesões , Traumatismo por Reperfusão/terapia , Ressuscitação/instrumentação , Choque Hemorrágico/terapia , Animais , Modelos Animais de Doenças , Suínos
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