title: Resuscitation from severe hemorrhagic shock after traumatic brain injury using saline, shed blood, or a blood substitute.
abstract: The original purpose of this study was to compare initial resuscitation of hemorrhagic hypotension after traumatic brain injury (TBI) with saline and shed blood. Based on those results, the protocol was modified and saline was compared to a blood substitute, diaspirin cross-linked hemoglobin (DCLHb). Two series of experiments were performed in anesthetized and mechanically ventilated (FiO2 = 0.4) pigs (35-45 kg). In Series 1, fluid percussion TBI (6-8 ATM) was followed by a 30% hemorrhage. At 120 min post-TBI, initial resuscitation consisted of either shed blood (n = 7) or a bolus of 3x shed blood volume as saline (n = 13). Saline supplements were then administered to all pigs to maintain a systolic arterial blood pressure (SAP) of >100 mmHg and a heart rate (HR) of <110 beats/min. In Series 2, TBI (4-5 ATM) was followed by a 35% hemorrhage. At 60 min post-TBI, initial resuscitation consisted of either 500 mL of DCLHb (n = 6) or 500 mL of saline (n = 5). This was followed by saline supplements to all pigs to maintain a SAP of >100 mmHg and a HR of <110 beats/min. In Series 1, most systemic markers of resuscitation (e.g., SAP, HR, cardiac output, filling pressures, lactate, etc.) were normalized, but there were 0/7 vs. 5/13 deaths within 5 h (P = 0.058) with blood vs. saline. At constant arterial O2 saturation (SaO2), mixed venous O2 saturation (SvO2), cerebral perfusion pressure (CPP), and cerebral venous O2 saturation (ScvO2) were all higher, intracranial pressure (ICP) was lower, and CO2 reactivity was preserved with blood vs. saline (all P < 0.05). In Series 2, SAP, ICP, CPP, and lactate were higher with DCLHb vs. saline (all P< 0.05). Cardiac output was lower even though filling pressure was markedly elevated with DCLHb vs. saline (both P< 0.05). Neither SvO2 nor cerebrovascular CO2 reactivity were improved, and ScvO2 was lower with DCLHb vs. saline (P < 0.05). All survived at least 72 h with neuropathologic changes that included sub-arachnoid hemorrhage, midline cerebellar necrosis, and diffuse axonal injury. These changes were similar with DCLHb vs. saline. Thus, whole blood was more effective than saline for resuscitation of TBI, whereas DCLHb was no more, and according to many variables, less effective than saline resuscitation. These experimental results are comparable to those in a recent multicenter trial using DCLHb for the treatment of severe traumatic shock. Further investigations in similar experimental models might provide some plausible explanations why DCLHb unexpectedly increased mortality in patients.
authors.affiliation: Department of Surgery, University of Tennessee Health Science Center, Memphis 38163, USA.
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Gibson
authors.forename: Robert A
authors.initials: RA
authors.lastname: Maxwell
authors.forename: John B
authors.initials: JB
authors.lastname: Schweitzer
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Fabian
authors.forename: Kenneth G
authors.initials: KG
authors.lastname: Proctor
mesh_terms: D000818:Animals; D001241:Aspirin / Q000031:analogs & derivatives* / Q000627:therapeutic use; D001802:Blood Substitutes / Q000627:therapeutic use; D001803:Blood Transfusion / Q000379:methods; D001921:Brain / Q000378:metabolism; D001930:Brain Injuries / Q000150:complications* / Q000503:physiopathology / Q000628:therapy; D002545:Brain Ischemia / Q000209:etiology / Q000517:prevention & control; D002245:Carbon Dioxide / Q000378:metabolism; D005260:Female; D006454:Hemoglobins / Q000627:therapeutic use; D007427:Intracranial Pressure / Q000187:drug effects; D008297:Male; D010100:Oxygen / Q000378:metabolism; D012151:Resuscitation / Q000379:methods*; D012771:Shock, Hemorrhagic / Q000209:etiology / Q000628:therapy*; D012965:Sodium Chloride / Q000627:therapeutic use; D015996:Survival Rate; D013552:Swine
chemical_list: D001802:Blood Substitutes; D006454:Hemoglobins; D002245:Carbon Dioxide; D012965:Sodium Chloride; C083478:diaspirin-cross-linked hemoglobin; D001241:Aspirin; D010100:Oxygen