Alginate plasma expander maintains perfusion and plasma viscosity during extreme hemodilution

Extreme hemodilution was performed in the hamster chamber window model using 6% Dextran 70, lowering systemic hematocrit by 60%. Animals were subsequently divided into three groups and hemodiluted to a hematocrit of 11% using 6% Dextran 70, 6% Dextran 500, and a 4% Dextran 70 + 0.7% alginate solution ( n = 6 each group). Final plasma viscosities were 1.4 ± 0.2, 2.2 ± 0.1, and 2.7 ± 0.2 cp, respectively, ( P < 0.05, high viscosity vs. low viscosity). Blood viscosities were 2.1 ± 0.2, 2.9 ± 0.4, and 3.9 ± 0.3 cp, respectively. The lowest blood and plasma viscosity group had a significantly lower functional capillary density, 37 ± 16%, whereas the two high-viscosity solutions were 71 ± 15% and 76 ± 12% ( P < 0.05, high viscosity vs. low viscosity), respectively. Arteriolar and venular flow in the Dextran 500 and alginate groups was higher than baseline (i.e., normal nontreated animals), whereas the low-viscosity group showed a reduction in flow. These microvascular changes were paralleled by changes in base excess, which was negative for the Dextran 70 group and positive for the other groups. However, tissue Po2 was uniformly low for all groups (average of 1.4 mmHg). Calculation of tissue oxygen consumption in the window chamber based on the microvascular data, flow, and intravascular Po2 showed that only the alginate + Dextran 70 solution-exchanged animals returned to baseline oxygen consumption, whereas the other groups were lower than baseline ( P < 0.05). These results show that hemodilution performed with high-viscosity plasma expanders yields systemic arterial pressures and functional capillary densities that are significantly higher ( P < 0.05) than those obtained with 6% Dextran 70, a fluid whose viscosity is similar to that of plasma. A condition for obtaining these results is that the oncotic pressure of the plasma expander be titrated to near normal, so that autotransfusion of fluid from the tissue into the vascular compartment does not reduce the effects of increasing plasma viscosity and increased shear stress on the microvascular wall.

Oxygen transport by low and normal oxygen affinity hemoglobin vesicles in extreme hemodilution

The oxygen transport capacity of phospholipid vesicles encapsulating purified Hb (HbV) produced with a Po2at which Hb is 50% saturated (P 50 ) of 8 (HbV8) and 29 mmHg (HbV29) was investigated in the hamster chamber window model by using microvascular measurements to determine oxygen delivery during extreme hemodilution. Two isovolemic hemodilution steps were performed with 5% recombinant albumin (rHSA) until Hct was 35% of baseline. Isovolemic exchange was continued using HbV suspended in rHSA solution to a total [Hb] of 5.7 g/dl in blood. P50was modified by coencapsulating pyridoxal 5′-phosphate. Final Hct was 11% for the HbV groups, with a plasma [Hb] of 2.1 ± 0.1 g/dl after exchange with HbV8or HbV29. A reference group was hemodiluted to Hct 11% with only rHSA. All groups showed stable blood pressure and heart rate. Arterial oxygen tensions were significantly higher than baseline for the HbV groups and the rHSA group and significantly lower for the HbV groups compared with the rHSA group. Blood pressure was significantly higher for the HbV8group compared with the HbV29group. Arteriolar and venular blood flows were significantly higher than baseline for the HbV groups. Microvascular oxygen delivery and extraction were similar for the HbV groups but lower for the rHSA group ( P < 0.05). Venular and tissue Po2were statistically higher for the HbV8vs. the HbV29and rHSA groups ( P < 0.05). Improved tissue Po2is obtained when red blood cells deliver oxygen in combination with a high- rather than low-affinity oxygen carrier.

EFFECTS OF COLLOID RESUSCITATION ON PERIPHERAL MICROCIRCULATION, HEMODYNAMICS, AND COLLOIDAL OSMOTIC PRESSURE DURING ACUTE SEVERE HEMORRHAGE IN RABBITS

We examined the effects of hydroxyethyl starch (HES) on the microcirculation, hemodynamics, and colloidal osmotic pressure in a rabbit model of hemorrhagic shock. A total of 40 rabbits was anesthetized with pentobarbital and isoflurane, and they were mechanically ventilated. An ear chamber was prepared to examine blood vessels by intravital microscopy. Shock was induced by removing nearly half of the circulating blood volume. Twenty rabbits received 20 mL of HES by intravenous infusion immediately after blood letting. Additional HES was then administered intravenously to a total volume of 100 mL. The other 20 rabbits (control) were intravenously given 40 mL of lactated Ringer's solution (LR), followed by additional LR to a total volume of 200 mL, administered under the same conditions as HES. After blood letting, arteriolar diameter decreased similarly in the the HES and LR groups (HES, 40.5% +/- 14.8% of the baseline value versus LR, 43.3% +/- 13.1%). After the completion of infusion, arteriolar diameter significantly recovered to 90.8% +/- 10.2% of the baseline value in the HES group as compared with only 62.6% +/- 10.7% in the LR group (P < 0.005). Recovery of arterial blood flow velocity and blood flow rate was also significantly better in the HES group than in the LR group (P < 0.005). Mean arteriolar pressure, central venous pressure, and plasma colloid osmotic pressure after the completion of infusion were significantly greater in the HES group than in the LR group (P < 0.005). We conclude that intravenous infusion of HES effectively maintains the microcirculation, hemodynamics, and colloidal osmotic pressure in a rabbit model of acute severe hemorrhage.

Elevated plasma viscosity in extreme hemodilution increases perivascular nitric oxide concentration and microvascular perfusion

We tested the hypothesis that high-viscosity (HV) plasma in extreme hemodilution causes wall shear stress to be greater than low-viscosity (LV) plasma, leading to enhanced production of nitric oxide (NO). The perivascular concentration of NO was measured in arterioles and venules and the tissue of the hamster chamber window model, subjected to acute extreme hemodilution, with a hematocrit (Hct) of 11% using Dextran 500 ( n = 6) or Dextran 70 ( n = 5) with final plasma viscosities of 1.99 ± 0.11 and 1.33 ± 0.04 cp, respectively. HV plasma significantly increased the periarteriolar, perivenular, and tissue NO concentration by 2.0, 1.9, and 1.4 times the control ( n = 7). The NO concentration with LV plasma was not statistically different from control. Arteriolar shear stress was significantly increased in HV plasma relative to LV plasma in arterioles but not in venules. Aortic endothelial NO synthase (eNOS) protein expression was increased with HV plasma but not with LV plasma. There was a weak correlation between perivascular NO concentration and the locally calculated shear stress induced by the procedures, when blood viscosity was corrected according to Hct values previously determined in studies of microvascular Hct distribution. The finding that the periarteriolar and venular NO concentration in HV plasma was the same although arteriolar shear stress was significantly greater than venular shear stress maybe be due to differences in vessel wall metabolism between arterioles and venules and the presence of NO transport through the blood stream in the microcirculation. Results support the concept that in extreme hemodilution HV plasma maintains functional capillary density through a NO-mediated vasodilatation.

Physiology, Pharmacology, and Rationale for Colloid Administration for the Maintenance of Effective Hemodynamic Stability in Critically Ill Patients

The semisynthetic colloid solutions (gelatins, dextrans, and hydroxyethyl starches) are complex drugs. Their principal role in the care of the critically ill is as plasma volume expanders, but they may also affect hemorrheology, hemostasis, and inflammatory processes. The pattern of beneficial and detrimental effects varies between products. Understanding of the physiology of plasma volume expansion, as well as the nature and magnitude of these additional pharmacological qualities, is necessary for rational prescription of these commonly used products. The composition of the solute carrier solution can influence the clinical effects of colloid solutions. A large amount of data from laboratory and small clinical studies is available to inform this choice of colloid in a variety of situations. Significant patient outcome data from large studies has until recently been lacking, and clinicians have continued to prescribe a variety of crystalloids and colloids for the maintenance of effective hemodynamic stability in critically ill patients. The recently published Saline vs Albumin Fluid Evaluation Study demonstrates that albumin has an equivalent effectiveness and safety profile to 0.9% saline as a resuscitation fluid. The choice of clinical endpoints to guide dosage (infused volume) of colloids is probably therefore more important than the choice between individual products.

Artificial colloids impair haemostasis. An in vitro study using thromboelastometry coagulation analysis

BACKGROUND

Hydroxyethyl starch (HES) solutions impair haemostatic mechanisms. The impact of the degree of substitution (DS) of a HES solution on thromboelastometry tracings is unclear. Therefore we tested the hypothesis of whether the DS has an effect on the haemostatic defect caused by HES, and assessed whole blood coagulation by thromboelastometry coagulation analysis (ROTEM, Pentapharm Co., Munich, Germany) in serial in vitro haemodilutions of colloids.

METHODS

Whole blood was withdrawn from 12 volunteers in a crossover study. Six per cent low-molecular weight HES with a high (HES MW 120 kDa/degree of substitution 0.7) and low (HES MW 130 kDa/0.4) degree of substitution, 4% succinylated gelatin (GEL) or 4% albumin (ALB) was added to citrated venous whole blood samples to make 20, 40, 60 vol.% end-concentrations of each of the solutions. Samples were analyzed by ROTEM.

RESULTS

There was a comparable decrease in maximum clot firmness (MCF) and shear elastic modulus [G = 5000 x MCF/(100-MCF)] by HES 120/0.7 and HES 130/0.4 at 20 and 40 vol.% dilutions. At 60 vol.% dilution HES 120/0.7 decreased less alpha-angle and MCF than HES 130/0.4 (P < 0.05). With moderate dilutions all colloids shortened coagulation time (CT). At 20, 40 and 60 vol.% dilutions MCF and G were more decreased in both HES groups than in the ALB and GEL groups (P < 0.05). Furthermore, at 40 and 60 vol.% dilutions G deteriorated more in the GEL than in the ALB group (P < 0.05).

CONCLUSION

In vitro the impact of the degree of substitution of HES solution on thromboelastometry coagulation analysis was modest. Haemodilution with gelatin and albumin induced fewer coagulation abnormalities than HES. In addition, the haemodilution with gelatin impaired coagulation more than albumin solution.

Mechanism of the effect of hydroxyethyl starch on reducing pulmonary capillary permeability in a rat model of sepsis

Hydroxyethyl starch (HES) is one of the most frequently used plasma substitutes. Recent studies have indicated that HES may reduce capillary leakage. The present in vivo study was performed to investigate the effects of HES on pulmonary capillary permeability, inflammatory mediators, and transcription factors in sepsis. Septic rats induced by cecal ligation and puncture (CLP) were treated with different doses of HES (7.5, 15, or 30 ml/kg, iv). At 5 or 12 hr after CLPq the rat lung tissues were collected. Pulmonary microvascular permeability, various cytokine levels (tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, and IL-6), mRNA expressions (cytokine-induced neutrophil chemoattractant (CINC), P-selectin, CD 11b/CD18 (Mac-1), and intercellular adhesion molecule-1 (ICAM-1)), and activities of nuclear factor (NF)-kappaB and activator protein (AP)-1 were determined in each group. HES, in a dose-related manner, significantly reduced pulmonary capillary permeability in the CLP model of sepsis. HES also down-regulated pulmonary proinflammatory cytokines (TNF-alpha, IL-1beta, and IL-6) and mRNA expressions (CINC and P-selectin), and inhibited pulmonary activities of NF-kappaB and AP-1. The results suggest that during sepsis HES reduces pulmonary capillary permeability and this beneficial effect of HES may act through down-regulation of inflammatory mediators and suppression of NF-kappaB and AP-1 activation.

Right atrial dimension-pressure relation during volume expansion is unaltered by pregnancy in the rat

Blood volume expands significantly during pregnancy, but afferent signals from cardiac receptors are reduced. In addition, during exogenous volume expansion, right atrial pressure (RAP) increases more for equivalent volumes in pregnant animals, implying reduced atrial compliance. To examine possible gestational alterations in atrial dimension during volume expansion, we compared the effects of volume expansion on RAP and right atrial dimension (RAD) in pregnant vs. virgin rats. Anesthetized animals were ventilated and catheterized for measurement of arterial pressure and RAP and for drug infusion. Through a parasternal incision, ultrasonic crystals were glued to the medial and lateral surfaces of the right atrium for measurement of RAD. Plasma volume and hematocrit were determined before experimentation. RAP, RAD, and arterial pressure were recorded at baseline and during progressive volume expansion (6% dextran, 60% of initial blood volume). Baseline RAP was similar in the two groups: 2.82 ± 0.40 and 2.72 ± 0.47 mmHg in pregnant and virgin rats, respectively. Basal RAD was significantly larger in pregnant than in virgin rats: 4.36 ± 0.66 vs. 3.36 ± 0.48 mm. Despite increased basal RAD in pregnant rats, the slope of the RAD-RAP relation during volume expansion was similar in the two groups. Results indicate that resting RAD is increased in pregnant rats and that the change in dimension during volume loads is similar to that in virgin rats. Thus, during pregnancy, the right atrium appears to accommodate the increased blood volume, and reduced afferent signaling most likely is due to mechanisms other than mechanical alterations of the atrium by expanded volume.

Effect of hydroxyethylstarch on renal function in cardiac surgery: a large scale retrospective study

BACKGROUND

Recent reports indicated negative effects of hydroxyethylstarch (HES) on renal function. The goal of this large scale retrospective study was to detect whether there was an association between postoperative deterioration of renal function and the use of HES 200 kD, 0.5 DS in the cardiac surgery setting.

METHODS

Retrospective analysis of daily collected data in 3124 patients who underwent coronary artery bypass and/or valvular surgery. Three groups were compared according to differences in fluid therapy: --GEL: gelatin was used as priming fluid of extracorporeal circulation (ECC) and for postoperative filling (n = 1276). --MIX: HES was used as priming fluid of ECC an gelatin was used for postoperative filling (n = 1008). --HES: HES was used as priming fluid of ECC and for postoperative filling (n = 840).

MAIN RESULTS

There were no significant differences in postoperative serum creatinine concentrations between the 3 groups: GEL: 12,2 +/- 0,5 mg/l; MIX: 12,3 +/- 0.5 mg/l; HES: 12,3 +/- 0.6 mg/l. The need for postoperative extrarenal epuration was not significantly different between the 3 periods: GEL: 2,9%; MIX: 3,1%; HES: 3,8%.

CONCLUSION

The use of HES 200 kD, 0.5 DS in cardiac surgery does not seem to be associated with a clinically significant deterioration of postoperative renal function.

[Hydroxyethyl starch solutions]

Hypovolemia is common among surgical, trauma, and intensive care unit patients. It can occur in the absence of obvious fluid loss secondary to vasodilatation or during generalized alterations of the endothelial barrier resulting in increased capillary permeability. Hydroxyethyl starch solutions are increasingly used for the volume replacement therapy. Hydroxyethyl starch solutions are synthetic colloids with the pharmacological properties that are the closest to natural colloids. Important characteristics for these products are molecular weight, their concentration, the degree of molar substitution, and the substitution pattern. In this review article a large variety of hydroxyethyl starch solutions, their physical and chemical characteristics, pharmacokinetics and metabolism, the main route of elimination, mechanism of action, effect on blood plasma volume, safety, tolerability and side effects (the risk of adverse effects on hemostasis, platelet function, frequency of pruritus, anaphylactoid reaction, incidence of rise in serum amylase) are presented.

Volume expansion of albumin, gelatin, hydroxyethyl starch, saline and erythrocytes after haemorrhage in the rat

OBJECTIVE

To compare the colloids 5% albumin, 4% gelatin and 6% hydroxyethyl starch (HES) 130/0.4 with each other and with saline, regarding their plasma-expanding effects after haemorrhage; these were also compared with the intravascular volume-expanding effect of re-transfusion with erythrocytes.

DESIGN

Controlled, prospective, randomised laboratory study.

SETTING

University research laboratory.

SUBJECTS

Thirty-five adult rats.

INTERVENTIONS

Plasma volume was determined (I(125) albumin tracer technique) after haemorrhage of 20 ml/kg and 3 h after a bolus infusion of 20 ml/kg of each of the colloids or 80 ml/kg of saline, or 6.7 ml/kg of erythrocytes diluted in 9 ml/kg of saline. Blood pressure, haematocrit (Hct), blood gases and physiological parameters were measured.

MEASUREMENTS AND RESULTS

Plasma volume after haemorrhage was 29.6+/-2.6 ml/kg (n=35). With the bolus infusion, plasma volume increased by 21.1+/-3.6 ml/kg in the albumin group (n=7), by 13.1+/-2.9 ml/kg in the gelatin group (n=7), by 13.8+/-2.2 ml/kg in the HES group (n=7), by 16.0+/-2.4 ml/kg in the saline group (n=7) and by 6.9+/-2.3 ml/kg in the erythrocyte group (n=7) 3 h after the infusion. In the latter group, there was a total increase in intravascular volume of 13.6+/-2.5 ml/kg including the erythrocyte volume. Arterial pressure was better preserved in the albumin and erythrocyte groups than in the other groups.

CONCLUSION

Albumin 5% was a more effective plasma volume expander than gelatin and HES. Saline, with a four times larger volume, and erythrocytes in about 1/3 of the volume had a similar volume-expanding effect to gelatin and HES.

Tyrosine kinase inhibition affects skate anion exchanger isoform I alterations after volume expansion

Upon exposure to hypotonic medium, skate red blood cells swell and then reduce their volume by releasing organic osmolytes and associated water. The regulatory volume decrease is inhibited by stilbenes and anion exchange inhibitors, suggesting involvement of the red blood cell anion exchanger skAE1. To determine the role of tyrosine phosphorylation, red blood cells were volume expanded with and without prior treatment with the tyrosine kinase inhibitor piceatannol. At the concentration used, 130 microM, piceatannol nearly completely inhibits p72(syk), a tyrosine kinase previously shown to phosphorylate skAE1 (M. W. Musch, E. H. Hubert, and L. Goldstein. J Biol Chem 274: 7923-7928, 1999). Hyposmotic-induced volume expansion stimulated association of p72(syk) with a light membrane fraction of skate red blood cells. Piceatannol did not inhibit this association but decreased hyposmotically stimulated increased skAE1 tyrosine phophorylation. Movement of skAE1 from an intracellular to a surface detergent-resistant membrane domain and tetramer formation were not inhibited by piceatannol treatment. Two effects of hyposmotic-induced volume expansion, decreased band 4.1 binding and increased ankyrin, were both inhibited by piceatannol. These results suggest that at least one event requiring p72(syk) activation is pivotal for hyposmotic-induced increased transport; however, steps that do not require tyrosine phosphorylation may also play a role.

Effects of Different Catecholamines on the Dynamics of Volume Expansion of Crystalloid Infusion

Background

The authors studied the influence of alpha, beta, and dopaminergic catecholamines on blood volume expansion in conscious normovolemic sheep before, during, and after a bolus infusion of a crystalloid.

Methods

A 0.9% NaCl bolus (24 ml/kg in 20 min) was infused in four paired experiments each: no drug, dopamine infusion (50 microg . kg . min), isoproterenol infusion (0.1 microg . kg . min), and phenylephrine infusion (3 microg . kg . min). Blood volume expansion was calculated by the dilution of blood hemoglobin concentration.

Results

Dopamine had little effect on peak blood volume expansion (12.7 +/- 0.9 ml/kg) compared with 0.9% NaCl (13.0 +/- 2.7 ml/kg); in contrast, isoproterenol augmented blood volume expansion (18.5 +/- 1.8 ml/kg), and phenylephrine reduced blood volume expansion (8.9 +/- 1.4 ml/kg). Two hours after the 0.9% NaCl bolus, sustained blood volume expansion was greatest in the isoproterenol protocol (12.2 ml/kg), whereas the dopamine protocol (6.8 ml/kg) remained similar to the control protocol (4.1 ml/kg), and the phenylephrine protocol had a net volume loss (-1.9 ml/kg). Some blood volume expansion differences were attributed to changes in renal function as phenylephrine infusion increased urinary output, whereas isoproterenol was associated with antidiuresis. However, dopamine caused diuresis and sustained augmentation of blood volume.

Conclusion

Catecholamines can alter the intravascular volume expansion of fluid therapy. beta-Receptor (isoproterenol) stimulation augmented blood volume expansion, whereas alpha (phenylephrine) stimulation reduced blood volume expansion. Combined dopaminergic, beta, and possibly alpha stimulation with dopamine augmented blood volume expansion and cardiac output while inducing diuresis.

Plasma volume expansion does not increase maximal cardiac output or VO2 max in lowlanders acclimatized to altitude

With altitude acclimatization, blood hemoglobin concentration increases while plasma volume (PV) and maximal cardiac output (Q̇max) decrease. This investigation aimed to determine whether reduction of Q̇max at altitude is due to low circulating blood volume (BV). Eight Danish lowlanders (3 females, 5 males: age 24.0 ± 0.6 yr; mean ± SE) performed submaximal and maximal exercise on a cycle ergometer after 9 wk at 5,260 m altitude (Mt. Chacaltaya, Bolivia). This was done first with BV resulting from acclimatization (BV = 5.40 ± 0.39 liters) and again 2–4 days later, 1 h after PV expansion with 1 liter of 6% dextran 70 (BV = 6.32 ± 0.34 liters). PV expansion had no effect on Q̇max, maximal O2 consumption (V̇o2), and exercise capacity. Despite maximal systemic O2 transport being reduced 19% due to hemodilution after PV expansion, whole body V̇o2 was maintained by greater systemic O2 extraction ( P < 0.05). Leg blood flow was elevated ( P < 0.05) in hypervolemic conditions, which compensated for hemodilution resulting in similar leg O2 delivery and leg V̇o2 during exercise regardless of PV. Pulmonary ventilation, gas exchange, and acid-base balance were essentially unaffected by PV expansion. Sea level Q̇max and exercise capacity were restored with hyperoxia at altitude independently of BV. Low BV is not a primary cause for reduction of Q̇max at altitude when acclimatized. Furthermore, hemodilution caused by PV expansion at altitude is compensated for by increased systemic O2 extraction with similar peak muscular O2 delivery, such that maximal exercise capacity is unaffected.

Iron oxide nanoparticles as magnetic resonance contrast agent for tumor imaging via folate receptor-targeted delivery

RATIONALE AND OBJECTIVE

Targeted delivery is a highly desirable strategy for diagnostic imaging because of enhanced efficacy and reduced dosage/toxicity. Receptor-targeting was used to deliver contrast-producing superparamagnetic iron oxide (IO) nanoparticle to receptor-expressing tumors for in vivo magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Nanometer-sized, dextran-coated (maghemite) IO particles were prepared by a precipitation method. They were tethered with N-hydroxysuccinimide-folate and fluorescence isothiocyanate (FITC). For in vitro study of delivery specificity and efficiency, KB cells, a human nasopharyngeal epidermal carcinoma cell line expressing surface receptors for folic acid, were used as positive targets, and A549 cells, a human lung carcinoma cell line which lacks folate receptors, were used as negative control targets. In vivo MR images were obtained using mouse models with subcutaneous tumor xenografts grown from implanted KB cells.

RESULTS

Internalization of nanoparticles into targeted cells only occurred when IO was conjugated to folate and when the folate receptors are available and accessible on the cells. The endocytosis was efficient and rapid, as 97.5% KB cells cultured with folate-FITC-IO showed FITC uptake after 1 hour of incubation. In in vivo MR imaging, an average intensity decrease of 38% was observed from precontrast to postcontrast images of the tumor, which was about three times the intensity decrease observed at a non-tumor-bearing muscle.

CONCLUSION

Successful in vivo MR imaging of folate receptor-expressing tumors targeted by IO nanoparticles was demonstrated for the first time.

[Effect of new hemocorrectors on heart mitochondrial oxidation in hemorrhagic shock]

In experimental model of hemorrhagic shock, the influence of new hemocorrectors, succinasole and sucksivil (1,4-naphtoquinone) on rabbit myocardial mitochondrial oxidation was studied. Both substances improved function of myocardial mitochondria. Administration of new hemocorrectors increased duration of life of animals subjected to hemorrhagic shock, improved hemodynamics, metabolism, normalized myocaidla mitochondrial functions and increased positive effect of shock therapy.

Elimination Rate Constant Describing Clearance of Infused Fluid from Plasma Is Independent of Large Infusion Volumes of 0.9% Saline in Sheep

Background

The purpose of this study was to determine the influence of varying large crystalloid infusion volumes, ranging from a volume that has been safely administered to volunteers to a volume that greatly exceeds a practical volume for studies in normovolemic humans, of rapidly infused 0.9% saline on the elimination rate constant in sheep.

Methods

Six sheep underwent three randomly ordered, 20 min, intravenous infusions of 0.9% saline in volumes of 25 ml/kg, 50 ml/kg and 100 ml/kg. Repeated measurements of arterial plasma dilution were analyzed using the volume kinetic approach to determine the apparent volumes of the central (V1) and peripheral (V2) body fluid spaces, the elimination rate constant (kr) describing clearance from the central fluid space and the rate constant (kt) for the diffusion of fluid between the central and the peripheral fluid spaces. The latter constant was split in to two constants, one describing flow out from the central fluid space and one describing flow into the central fluid space. Urinary output was measured in all sheep.

Results

kr was comparable at each infused volume (38.3 +/- 4.5, 32.2 +/- 4.2, and 36.7 +/- 7.0 ml/min, respectively, in the 25 ml/kg, 50 ml/kg, and 100 ml/kg protocols). However, for the largest infusion, other kinetic parameters were influenced by the magnitude of the infusion. V2 was significantly increased (P &lt; 0.05) and the area under the dilution-time curve divided by the infused volume was 20% lower for the largest infusion (P &lt; 0.03). Although urinary output increased as the infusion volume increased, only 59% of the administered volume had been excreted at 180 min after the 100 ml/kg infusion as compared with approximately 90% after the other two infusions (P &lt; 0.01).

Conclusions

Elimination from the central fluid space of large, rapidly infused volumes of saline solution is independent of infused volume. Larger volumes are apparently cleared from the central fluid space (V1) by expansion of a peripheral volume (V2) as renal excretion fails to increase in proportion to the volume of infused fluid.

Increased Cerebral Tissue Oxygen Tension After Extensive Hemodilution with a Hemoglobin-Based Oxygen Carrier

Transfusion of anemic patients with hemoglobin-based oxygen carriers (HBOCs) may improve cerebral oxygen delivery. Conversely, cerebral vasoconstriction, associated with HBOC transfusion, could limit optimal cerebral tissue oxygenation. We hypothesized that hemodilution with a HBOC would maintain cerebral tissue oxygenation, despite the occurrence of cerebral vasoconstriction. Isoflurane-anesthetized rats (100% oxygen) underwent direct measurement of mean arterial blood pressure (MAP), caudate tissue oxygen tension (P(Br)o(2)), and regional cortical cerebral blood flow (rCBF) before and after 50% of the estimated blood volume (30 mL/kg) was exchanged with either an HBOC (hemoglobin raffimer; Hemolink) or pentastarch (n = 6). Hemodilution with hemoglobin raffimer caused a transient increase in P(Br)o(2) from 24.9 +/- 13.3 mm Hg to 32.2 +/- 19.1 mm Hg (P < 0.05), a sustained increase in MAP, and no change in rCBF. Arterial blood oxygen content was maintained despite an increase in methemoglobin and reduced oxygen saturation. Hemodilution with pentastarch caused a transient increase in MAP, no change in P(Br)o(2), and a sustained increase in rCBF (P < 0.05), whereas the hemoglobin concentration and oxygen content were significantly reduced. Hemodilution with hemoglobin raffimer augmented P(Br)o(2) and prevented the increase in rCBF observed after similar hemodilution with pentastarch. These data suggest that transfusion with hemoglobin raffimer may help to maintain cerebral oxygenation during severe anemia.

Reduced baroreflex control of heart period after bed rest is normalized by acute plasma volume restoration

Adaptation to spaceflight or head-down-tilt bed rest leads to hypovolemia and an apparent abnormality of baroreflex regulation of cardiac period. In a previous study, we demonstrated that both chronic (2 wk) head-down-tilt bed rest and acute induced hypovolemia led to similar impairments in spontaneous baroreflex control of cardiac period, suggesting that a reduction in plasma volume may be responsible for this abnormality after bed rest. Therefore we hypothesized that this reduced "baroreflex function" could be restored by intravenous volume infusion equivalent to the reduction in plasma volume after bed rest. Six healthy subjects underwent 2 wk of -6 degrees head-down bed rest. Beat-by-beat arterial blood pressure and ECG were recorded during 6 min of spontaneous respiration and fixed-rate breathing (0.2 Hz), and transfer function analysis between systolic blood pressure and R-R interval was performed. Plasma volume was measured with Evans blue dye, and cardiac filling pressures were directly measured (Swan-Ganz catheter). After bed rest, studies were repeated before and after plasma volume restoration, with which both plasma volume and left ventricular end-diastolic pressure were restored to pre-bed rest levels by intravenous dextran40 infusion (288 +/- 31 ml). Transfer function gain in the high-frequency range, used as an index of vagally mediated arterial-cardiac baroreflex function, decreased significantly (13.4 +/- 3.1 to 8.1 +/- 2.9 ms/mmHg, P < 0.05) after bed rest. However, reduced transfer function gain was normalized to the pre-bed rest level (12.2 +/- 3.6 ms/mmHg) after precise plasma volume restoration. This result confirms that reductions in plasma volume, rather than a unique autonomic nervous system adaptation to bed rest, are largely responsible for the observed changes in spontaneous arterial-cardiac baroreflex function after bed rest.

Microvascular pressure and functional capillary density in extreme hemodilution with low- and high-viscosity dextran and a low-viscosity Hb-based O2 carrier

Blood losses are usually corrected initially by the restitution of volume with plasma expanders and subsequently by the restoration of oxygen-carrying capacity using either a blood transfusion or possibly, in the near future, oxygen-carrying plasma expanders. The present study was carried out to test the hypothesis that high-plasma viscosity hemodilution maintains perfused functional capillary density (FCD) by preserving capillary pressure. Microvascular pressure responses to extreme hemodilution with low- (LV) and high-viscosity (HV) plasma expanders and an exchange transfusion with a polymerized bovine cell-free Hb (PBH) solution were analyzed in the awake hamster window chamber model ( n = 26). Systemic hematocrit was reduced from 50% to 11%. PBH produced a greater mean arterial blood pressure than the nonoxygen carriers. FCD was higher after a HV plasma expander (70 ± 15%) vs. PBH (47 ± 12%). Microvascular pressure spanning the capillary network was higher after a HV plasma expander (16–19 mmHg) compared with PBH (12–16 mmHg) and a LV plasma expander (11–14 mmHg) but lower than control (22–26 mmHg). FCD was found to be directly proportional to capillary pressure. The use of a HV plasma expander in extreme hemodilution maintained the number of perfused capillaries and tissue perfusion by comparison with a LV plasma expander due to increased mean arterial blood pressure and capillary pressure. The use of PBH increased mean arterial pressure but reduced capillary pressure due to vasoconstriction and did not maintain FCD.

Oxygen delivery and consumption in the microcirculation after extreme hemodilution with perfluorocarbons

The oxygen transport capacity of fluorocarbons was investigated in the hamster chamber window model microcirculation to determine the rate at which oxygen is delivered to the tissue in conditions of extreme hemodilution [hematocrit (Hct) 11%]. Hydroxyethlyl starch (HES 200; 200 kDa molecular mass) was used as a plasma expander for two isovolemic hemodilutions performed with 10% HES 200 until a Hct of 65%. A third step reduced the Hct to 75% of baseline and was performed with either HES 200 or a 60% perfluorocarbon (PFC) emulsion. Comparisons of HES 200-only-hemodiluted animals versus 4.2 g/kg PFC emulsion-hemodiluted animals were made at 21% and 100% normobaric oxygen ventilation. It was found that systemic and microvascular oxygen delivery was 25% and 400% higher in the PFC animals compared with HES 200 animals, respectively, showing that PFCs deliver oxygen to the tissue when combined with hyperoxic ventilation in the present experiments, with no evidence of vasoconstriction or impaired microvascular function. Oxygen ventilation (100%) led to a positive base excess for the PFC group (5.5 ± 2.5 mmol/l) versus a negative balance (−0.8 ± 1.4 mmol/l) for the HES 200 group, suggesting that microvascular findings corresponded to systemic events.

Perflubron emulsion improves hepatic microvascular integrity and mitochondrial redox state after hemorrhagic shock

Hemorrhagic shock is associated with decreased systemic oxygen delivery, but also with impaired microvascular perfusion, which can result in diminished local oxygen availability even in the presence of adequate cardiac output after resuscitation. Beside surgical interventions to control blood loss, transfusion of stored packed red blood cells represents the current standard of care in the management of severe hemorrhagic shock. Because stored red blood cells are less deformable and show a higher O2 affinity that affects the O2 off-load to tissues, perfluorocarbon-based artificial oxygen carriers might improve local O2 delivery under these conditions. To test this, rats were subjected to hemorrhagic shock (1 h, mean arterial pressure [MAP] 30-35 mmHg) and were resuscitated with fresh whole blood, pentastarch, stored red blood cells, perflubron emulsion (2.7 and 5.4 g/kg body weight) together with pentastarch, or stored red blood cells together with 2.7 g/kg perflubron emulsion. Hepatic microcirculation, tissue oxygenation, and mitochondrial redox state were investigated by intravital microscopy. In addition, hepatocellular function and liver enzyme release were determined. After hemorrhagic shock and resuscitation with perflubron emulsion, volumetric sinusoidal blood flow was significantly increased compared with resuscitation with stored red blood cells. Furthermore, resuscitation with perflubron emulsion resulted in higher hepatic tissue PO2 and normalized mitochondrial redox potential, which was accompanied by lessened hepatocellular injury as well as improved liver function. These results indicate that, in this model of hemorrhagic shock, asanguineous fluid resuscitation with addition of perflubron emulsion is superior to stored blood or pentastarch alone with respect to increased local O2 availability on the cellular level. This effect is primarily due to improved restoration of hepatic microcirculatory integrity.

Interaction of prolactin, ANPergic, oxytocinergic and adrenal systems in response to extracellular volume expansion in rats

The present study evaluated the effect of acute extracellular volume expansion (EVE) induced by intravenous injection of isotonic (0.15 m NaCl) or hypertonic saline (0.3 m NaCl) on prolactin, corticosterone, vasopressin, oxytocin and atrial natriuretic peptide (ANP) secretion. Male Wistar rats were treated with bromocriptine, sulpiride or dexamethasone. After isotonic and hypertonic EVE, the control group showed a significant increase in the plasma concentrations of prolactin, corticosterone, ANP and oxytocin. The increase in ANP and oxytocin levels in response to hypertonic EVE was more pronounced than to isotonic EVE. Bromocriptine and sulpiride treatments did not modify corticosterone, ANP and oxytocin responses to either isotonic or hypertonic EVE. The increases in prolactin and oxytocin, but not ANP, were blocked in dexamethasone pretreated rats. In conclusion, isotonic or hypertonic EVE induced an increase in the plasma concentrations of prolactin, corticosterone, ANP and oxytocin. The increases in ANP and oxytocin were independent of plasma concentrations of prolactin. The increases in prolactin and oxytocin were blocked by the inhibition of the hypothalamo-pituitary-adrenal (HPA) axis by dexamethasone. However, dexamethasone did not alter the increase in ANP secretion induced by isotonic or hypertonic EVE. Therefore, prolactin might participate in regulation of the hydroelectrolytic balance in mammals; however, in the present study, there was no evidence for direct interaction with ANPergic and oxytocinergic systems. In addition, the responses of prolactin and oxytocin induced by isotonic or hypertonic EVE are modulated by the HPA axis.

Ringer's solution but not hydroxyethyl starch or modified fluid gelatin enhances platelet microvesicle formation in a porcine model of septic shock †

BACKGROUND

Sepsis is associated with volume deficit and clotting system activation. Platelet activation in sepsis results in an increased formation of microvesicles, which in turn, have been associated with increased mortality. We hypothesized an effect of different volume replacement solutions on platelet-derived microvesicle formation in septic shock.

METHODS

Anaesthetized, mechanically ventilated and multi-catheterized pigs received 1 g kg(-1) body weight faeces into the abdominal cavity to induce sepsis and were observed over 8 h. Five animals in each group received volume replacement therapy with modified fluid gelatin 4% or 8% (MFG4%, MFG8%), 6% hydroxyethylstarch (HES) 200/0.5 or Ringer's solution (RS) to maintain a central venous pressure of 12 mm Hg. Flow cytometry was used for determination of microvesicles before induction of sepsis (baseline) and after 8 h. Platelets and microvesicles were identified with an anti-platelet monoclonal Ab and a secondary antibody. Microvesicles were determined as the smallest 1-3% positive cells in forward scatter. Intergroup comparisons were performed using Wilks-Lambda and Ryan-Einot-Gabriel-Welsh F-test. Differences within groups were compared using a two-tailed Student's t-test.

RESULTS

Baseline values were considered as 100%. While microvesicle formation was reduced in HES (73 (sd 19)%), MFG4% (63 (41)%) and MFG8% groups (53 (17)%), an increase in the RS-group (210 (121)%) was observed. Eight hours after induction of sepsis, formation of microvesicles was significantly higher in the RS group compared to all colloid-treated groups.

CONCLUSION

In this porcine septic shock model the formation of platelet-derived microvesicles was significantly increased by volume replacement with Ringer's solution in comparison to colloid solutions.

Hemodynamic response and oxygen transport in pigs resuscitated with maleimide-polyethylene glycol-modified hemoglobin (MP4)

Cell-free Hb increases systemic and pulmonary pressure and resistance and reduces cardiac output and heart rate in animals and humans, effects that have limited their clinical development as “blood substitutes.” The primary aim of this study was to evaluate the hemodynamic response to infusion of several formulations of a new polyethylene glycol (PEG)-modified human Hb [maleimide PEG Hb (MalPEGHb)] in swine, an animal known to be sensitive to Hb-induced vasoconstriction. Anesthetized animals underwent controlled hemorrhage (50% of blood volume), followed by resuscitation (70% of shed volume) with 10% pentastarch (PS), 4% MalPEG-Hb in lactated Ringer (MP4), 4% MalPEG-Hb in pentastarch (HS4), 2% MalPEG-Hb in pentastarch (HS2), or 4% stroma-free Hb in lactated Ringer solution (SFH). Compared with baseline, restoration of blood volume after resuscitation was similar and not significantly different for the PS (103%), HS2 (99%), HS4 (106%), and MP4 (87%) animals but significantly less for the SFH animals (66%) ( P < 0.05). All solutions that contained MalPEG-Hb restored mean arterial and pulmonary pressure and cardiac output. Systemic vascular resistance was unchanged, and pulmonary arterial pressure and resistance were increased slightly. Both systemic and pulmonary vascular resistance increased significantly in animals that received SFH, despite less adequate blood volume restoration. Oxygen consumption was maintained in all animals that received MalPEG-Hb, but not PS. Base excess improved only with MalPEG-Hb and PS, but not SFH. Red blood cell O2extraction was significantly increased in animals that received Hb, regardless of formulation. These data demonstrate resuscitation with MalPEG-human Hb without increasing systemic vascular resistance and support our previous observations in animals suggesting that the efficacy of low concentrations of PEG-Hb in the plasma results from reduced vasoconstriction.