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Renberg M, Karlsson T, Dahlquist A, Luckhurst C, Gustavsson J, Arborelius U, Risling M, Günther M. The anesthesiologist's guide to swine trauma physiology research: a report of two decades of experience from the experimental traumatology laboratory. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02542-7. [PMID: 38780782 DOI: 10.1007/s00068-024-02542-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Swine are one of the major animal species used in translational research, with unique advantages given the similar anatomic and physiologic characteristics as man, but the investigator needs to be familiar with important differences. This article targets clinical anesthesiologists who are proficient in human monitoring. We summarize our experience during the last two decades, with the aim to facilitate for clinical and non-clinical researchers to improve in porcine research. METHODS This was a retrospective review of 337 swine with a mean (SD) weight 60 (4.2) kg at the Experimental Traumatology laboratory at Södersjukhuset (Stockholm south general hospital) between 2003 and 2023, including laboratory parameters and six CT-angiography examinations. RESULTS Swine may be ventilated through the snout using a size 2 neonatal mask. Intubate using a 35 cm miller laryngoscope and an intubating introducer. Swine are prone to alveolar atelectasis and often require alveolar recruitment. Insert PA-catheters through a cut-down technique in the internal jugular vein, and catheters in arteries and veins using combined cut-down and Seldinger techniques. Cardiopulmonary resuscitation is possible and lateral chest compressions are most effective. Swine are prone to lethal ventricular arrhythmias, which may be reversed by defibrillation. Most vital parameters are similar to man, with the exception of a higher core temperature, higher buffer bases and increased coagulation. Anesthesia methods are similar to man, but swine require five times the dose of ketamine. CONCLUSION Swine share anatomical and physiological features with man, which allows for seamless utilization of clinical monitoring equipment, medication, and physiological considerations.
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Affiliation(s)
- Mattias Renberg
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Tomas Karlsson
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Albin Dahlquist
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Claire Luckhurst
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden
| | - Ulf Arborelius
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden
| | - Mårten Risling
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education Södersjukhuset, Section of Anesthesiology and Intensive care, Stockholm, Sweden.
- Department of Neuroscience, Section of Experimental Traumatology, Karolinska Institutet, Biomedicum- 8B, SE-171 77, Stockholm, Sweden.
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Zhang LY, Zhang HY. Torso hemorrhage: noncompressible? never say never. Eur J Med Res 2024; 29:153. [PMID: 38448977 PMCID: PMC10919054 DOI: 10.1186/s40001-024-01760-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
Since limb bleeding has been well managed by extremity tourniquets, the management of exsanguinating torso hemorrhage (TH) has become a hot issue both in military and civilian medicine. Conventional hemostatic techniques are ineffective for managing traumatic bleeding of organs and vessels within the torso due to the anatomical features. The designation of noncompressible torso hemorrhage (NCTH) marks a significant step in investigating the injury mechanisms and developing effective methods for bleeding control. Special tourniquets such as abdominal aortic and junctional tourniquet and SAM junctional tourniquet designed for NCTH have been approved by FDA for clinical use. Combat ready clamp and junctional emergency treatment tool also exhibit potential for external NCTH control. In addition, resuscitative endovascular balloon occlusion of the aorta (REBOA) further provides an endovascular solution to alleviate the challenges of NCTH treatment. Notably, NCTH cognitive surveys have revealed that medical staff have deficiencies in understanding relevant concepts and treatment abilities. The stereotypical interpretation of NCTH naming, particularly the term noncompressible, is the root cause of this issue. This review discusses the dynamic relationship between TH and NCTH by tracing the development of external NCTH control techniques. The authors propose to further subdivide the existing NCTH into compressible torso hemorrhage and NCTH' (noncompressible but REBOA controllable) based on whether hemostasis is available via external compression. Finally, due to the irreplaceability of special tourniquets during the prehospital stage, the authors emphasize the importance of a package program to improve the efficacy and safety of external NCTH control. This program includes the promotion of tourniquet redesign and hemostatic strategies, personnel reeducation, and complications prevention.
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Affiliation(s)
- Lian-Yang Zhang
- Department of Trauma Surgery, War Trauma Medical Center, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Hua-Yu Zhang
- Department of Trauma Surgery, War Trauma Medical Center, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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Karlsson T, Brännström A, Gellerfors M, Gustavsson J, Günther M. Comparison of emergency surgical cricothyroidotomy and percutaneous cricothyroidotomy by experienced airway providers in an obese, in vivo porcine hemorrhage airway model. Mil Med Res 2022; 9:57. [PMID: 36217208 PMCID: PMC9552401 DOI: 10.1186/s40779-022-00418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/20/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Emergency front-of-neck airway (eFONA) is a life-saving procedure in "cannot intubate, cannot oxygenate" (CICO). The fastest and most reliable method of eFONA has not been determined. We compared two of the most advocated approaches: surgical cricothyroidotomy and percutaneous cricothyroidotomy, in an obese, in vivo porcine hemorrhage model, designed to introduce real-time physiological feedback, relevant and high provider stress. The primary aim was to determine the fastest method to secure airway. Secondary aims were arterial saturation and partial pressure of oxygen, proxy survival and influence of experience. METHODS Twelve pigs, mean weight (standard deviation, SD) (60.3 ± 4.1) kg, were anesthetized and exposed to 25-35% total blood volume hemorrhage before extubation and randomization to Seldinger technique "percutaneous cricothyroidotomy" (n = 6) or scalpel-bougie-tube technique "surgical cricothyroidotomy" (n = 6). Specialists in anesthesia and intensive care in a tertiary referral hospital performed the eFONA, simulating an actual CICO-situation. RESULTS In surgical cricothyroidotomy vs. percutaneous cricothyroidotomy, the median (interquartile range, IQR) times to secure airway were 109 (IQR 71-130) s and 298 (IQR 128-360) s (P = 0.0152), arterial blood saturation (SaO2) were 74.7 (IQR 46.6-84.2) % and 7.9 (IQR 4.1-15.6) % (P = 0.0167), pO2 were 7.0 (IQR 4.7-7.7) kPa and 2.0 (IQR 1.1-2.9) kPa (P = 0.0667), and times of cardiac arrest (proxy survival) were 137-233 s, 190 (IQR 143-229), from CICO. All six animals survived surgical cricothyroidotomy, and two of six (33%) animals survived percutaneous cricothyroidotomy. Years in anesthesia, 13.5 (IQR 7.5-21.3), did not influence time to secure airway. CONCLUSION eFONA by surgical cricothyroidotomy was faster and had increased oxygenation and survival, when performed under stress by board certified anesthesiologists, and may be an indication of preferred method in situations with hemorrhage and CICO, in obese patients.
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Affiliation(s)
- Tomas Karlsson
- Department of Clinical Science and Education, Section of Anesthesiology and Intensive Care, Karolinska Institutet, 11883, Stockholm, Sweden.
| | - Andreas Brännström
- Department of Neuroscience, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Mikael Gellerfors
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet, 11883, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17177, Stockholm, Sweden.,Swedish Air Ambulance (SLA), 79291, Mora, Sweden.,Rapid Response Cars, 18233, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anesthesiology and Intensive Care, Karolinska Institutet, 11883, Stockholm, Sweden.,Department of Neuroscience, Karolinska Institutet, 17177, Stockholm, Sweden
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Soeyland T, Hollott JD, Garner A. External Aortic Compression in Noncompressible Truncal Hemorrhage and Traumatic Cardiac Arrest: A Scoping Review. Ann Emerg Med 2021; 79:297-310. [PMID: 34607742 DOI: 10.1016/j.annemergmed.2021.07.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/10/2021] [Accepted: 07/26/2021] [Indexed: 11/19/2022]
Abstract
External aortic compression has been investigated as a treatment for non-compressible truncal haemorrhage in trauma patients. We sought to systematically gather and tabulate the available evidence around external aortic compression. We were specifically interested in its ability to achieve hemostasis and aid in resuscitation of traumatic arrest and severe shock and to consider physiological changes and adverse effects. A scoping review approach was chosen due to the highly variable existing literature. We were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the specific extension for scoping reviews. Searches were done on PubMed and Scopus databases in October 2020. We found that a range of studies have investigated external aortic compression in a variety of settings, including case reports and small case series, porcine hemorrhage models and effects on healthy volunteers. External aortic compression for postpartum hemorrhage in a single center provided some evidence of effectiveness. Overall the level of evidence is limited, however, external aortic compression does appear able to achieve cessation of distal blood flow. Furthermore, it appears to improve many relevant physiological parameters in the setting of hypovolemic shock. Application for more than 60 minutes appears to cause increasingly problematic complications. In conclusion we find that the role of external aortic compression warrants further research. The intervention may have a role as a bridge to definitive treatment of noncompressible truncal haemorrahge.
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Affiliation(s)
- Torgrim Soeyland
- Hunter Retrieval Service, John Hunter Hospital, NSW Health, New South Wales, Australia.
| | - John David Hollott
- Hunter Retrieval Service, John Hunter Hospital, NSW Health, New South Wales, Australia
| | - Alan Garner
- Nepean Clinical School, University of Sydney, Sydney, Australia; Trauma Services, Nepean Hospital, Kingswood, Sydney, Australia
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Increased crystalloid fluid requirements during zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) versus Abdominal Aortic and Junctional Tourniquet (AAJT) after class II hemorrhage in swine. Eur J Trauma Emerg Surg 2021; 48:335-344. [PMID: 33515048 PMCID: PMC7846491 DOI: 10.1007/s00068-020-01592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022]
Abstract
Purpose Pelvic and lower junctional hemorrhage result in a significant amount of trauma related deaths in military and rural civilian environments. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infra-renal (zone 3) Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are two options for resuscitation of patients with life threatening blood loss from and distal to the pelvis. Evidence suggest differences in the hemodynamic response between AAJT and zone 3 REBOA, but fluid management during resuscitation with the devices has not been fully elucidated. We compared crystalloid fluid requirements (Ringer’s acetate) between these devices to maintain a carotid mean arterial pressure (MAP) > 60 mmHg. Methods 60 kg anesthetized and mechanically ventilated male pigs were subjected to a mean 1030 (range 900–1246) mL (25% of estimated total blood volume, class II) haemorrhage. AAJT (n = 6) or zone 3 REBOA (n = 6) were then applied for 240 min. Crystalloid fluids were administered to maintain carotid MAP. The animals were monitored for 30 min after reperfusion. Results Cumulative resuscitative fluid requirements increased 7.2 times (mean difference 2079 mL; 95% CI 627–3530 mL) in zone 3 REBOA (mean 2412; range 800–4871 mL) compared to AAJT (mean 333; range 0–1000 mL) to maintain target carotid MAP. Release of the AAJT required vasopressor support with norepinephrine infusion for a mean 9.6 min (0.1 µg/kg/min), while REBOA release required no vasopressor support. Conclusion Zone 3 REBOA required 7.2 times more crystalloids to maintain the targeted MAP. The AAJT may therefore be considered in a situation of hemorrhagic shock to limit the need for crystalloid infusions, although removal of the AAJT caused more severe hemodynamic and metabolic effects which required vasopressor support.
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Balian F, Garner AA, Weatherall A, Lee A. First experience with the abdominal aortic and junctional tourniquet in prehospital traumatic cardiac arrest. Resuscitation 2020; 156:210-214. [PMID: 32979403 DOI: 10.1016/j.resuscitation.2020.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/22/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The Abdominal Aortic and Junctional Tourniquet (AAJT) increased systemic vascular resistance, mean arterial pressure, carotid blood flow and rate of return of spontaneous circulation (ROSC) in animals with hypovolaemic traumatic cardiac arrest (TCA). The objective of this study was to report the first experience of the use of the AAJT as part of a pre-hospital TCA algorithm. METHODS This is a descriptive case series of the use of the AAJT in patients with TCA in a civilian physician-led pre-hospital trauma service in Sydney, Australia between June 2015 to August 2019. Cases were identified and data sourced from routinely collected data sets within the retrieval service. RESULTS During the study, 44 TCAs were attended, 22 with AAJT application. Mean time (standard deviation) to AAJT application since last signs of life was 16 (9) min. Eighteen (16 males, 2 females) patients, with median age (interquartile range) of 40 (25-58) years, were included for analysis. Seventeen patients (94%) had blunt trauma. Sixteen patients (89%) were in TCA at the time of service contact, 11 (61%) had a change in electrical activity, 4 (22%) had ROSC, and of the 6 with documented end-tidal carbon dioxide, the mean rise was 24.0 mmHg (95% CI 12.6-35.4) (P = 0.003). Three patients (17%) had sustained ROSC on arrival to the Emergency Department. No patients survived to hospital discharge. CONCLUSION Physiological changes were demonstrated but there were no survivors. Further research focusing on faster application times may be associated with improved outcomes.
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Affiliation(s)
- Fay Balian
- CareFlight NSW, Redbank Rd, Westmead, NSW 2145, Australia; Royal Prince Alfred Hospital, Sydney, Australia.
| | - Alan A Garner
- Trauma Department, Nepean Hospital, Derby St, Kingswood, NSW 2747, Australia; Universityof Sydney, Australia.
| | - Andrew Weatherall
- CareFlight NSW, Redbank Rd, Westmead, NSW 2145, Australia; Division of Child and Adolescent Health, The University of Sydney, Australia; The Children's Hospital at Westmead, Australia.
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
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