title: Tissue oxygen monitoring during hemorrhagic shock and resuscitation: a comparison of lactated Ringer's solution, hypertonic saline dextran, and HBOC-201.
abstract: BACKGROUND
  The ideal resuscitation fluid for the trauma patient would be readily available to prehospital personnel, universally compatible, effective when given in small volumes, and capable of reversing tissue hypoxia in critical organ beds. Recently developed hemoglobin-based oxygen-carrying solutions possess many of these properties, but their ability to restore tissue oxygen after hemorrhagic shock has not been established. We postulated that a small-volume resuscitation with HBOC-201 (Biopure) would be more effective than either lactated Ringer's (LR) solution or hypertonic saline dextran (HSD) in restoring baseline tissue oxygen tension levels in selected tissue beds after hemorrhagic shock. We further hypothesized that changes in tissue oxygen tension measurements in the deltoid muscle would reflect the changes seen in the liver and could thus be used as a monitor of splanchnic resuscitation.
  
  
  METHODS
  This study was a prospective, blinded, randomized resuscitation protocol using anesthetized swine (n = 30), and was modeled to approximate an urban prehospital clinical time course. After instrumentation and splenectomy, polarographic tissue oxygen probes were placed into the liver (liver PO2) and deltoid muscle (muscle PO2) for continuous tissue oxygen monitoring. Swine were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg over 20 minutes, shock was maintained for another 20 minutes, and then 100% oxygen was administered. Animals were then randomized to receive one of three solutions: LR (12 mL/kg), HSD (4 mL/kg), or HBOC-201 (6 mL/kg). Physiologic variables were monitored continuously during all phases of the experiment and for 2 hours postresuscitation.
  
  
  RESULTS
  At a MAP of 40 mm Hg, tissue PO2 was 20 mm Hg or less in both the liver and muscle beds. There were no significant differences in measured liver or muscle PO2 values after resuscitation with any of the three solutions in this model of hemorrhagic shock. When comparing the hemodynamic effects of resuscitation, the cardiac output was increased from shock values in all three animal groups with resuscitation, but was significantly higher in the animals resuscitated with HSD. Similarly, MAP was increased by all solutions during resuscitation, but remained significantly below baseline except in the group of animals receiving HBOC-201 (p < 0.01). HBOC-201 was most effective in both restoring and sustaining MAP and systolic blood pressure. There was excellent correlation between liver and deltoid muscle tissue oxygen values (r = 0.8, p < 0.0001).
  
  
  CONCLUSIONS
  HBOC-201 can be administered safely in small doses and compared favorably to resuscitation with HSD and LR solution in this prehospital model of hemorrhagic shock. HBOC-201 is significantly more effective than HSD and LR solution in restoring MAP and systolic blood pressure to normal values. Deltoid muscle PO2 reflects liver PO2 and thus may serve as an index of the adequacy of resuscitation in critical tissue beds.
authors.affiliation: San Francisco Injury Center, University of California, USA. pknudson@sfghsurg.ucsf.edu
authors.forename: M Margaret
authors.initials: MM
authors.lastname: Knudson
authors.forename: Seong
authors.initials: S
authors.lastname: Lee
authors.forename: Vanessa
authors.initials: V
authors.lastname: Erickson
authors.forename: Diane
authors.initials: D
authors.lastname: Morabito
authors.forename: Nikita
authors.initials: N
authors.lastname: Derugin
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Manley
mesh_terms: D000818:Animals; D001794:Blood Pressure / Q000187:drug effects; D001802:Blood Substitutes / Q000627:therapeutic use*; D003911:Dextrans / Q000627:therapeutic use*; D006339:Heart Rate / Q000187:drug effects; D006454:Hemoglobins; D007552:Isotonic Solutions / Q000627:therapeutic use*; D008099:Liver / Q000187:drug effects; D008297:Male; D009132:Muscles / Q000187:drug effects; D010101:Oxygen Consumption; D010952:Plasma Substitutes / Q000627:therapeutic use*; D012151:Resuscitation / Q000379:methods*; D000077325:Ringer's Lactate; D012462:Saline Solution, Hypertonic; D012771:Shock, Hemorrhagic / Q000628:therapy*; D013552:Swine
chemical_list: D001802:Blood Substitutes; D003911:Dextrans; D006454:Hemoglobins; D007552:Isotonic Solutions; D010952:Plasma Substitutes; D000077325:Ringer's Lactate; D012462:Saline Solution, Hypertonic; C096798:HBOC 201