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Edwards TH, Venn EC, Le TD, Grantham LE, Hogen T, Ford R, Ewer N, Gunville R, Carroll C, Taylor A, Hoareau GL. Comparison of Shelf-stable and Conventional Resuscitation Products in a Canine Model of Hemorrhagic Shock. J Trauma Acute Care Surg 2024:01586154-990000000-00721. [PMID: 38706102 DOI: 10.1097/ta.0000000000004332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Treatment of severe hemorrhagic shock typically involves hemostatic resuscitation with blood products. However, logistical constraints often hamper the wide distribution of commonly used blood products like whole blood. Shelf-stable blood products and blood substitutes are poised to be able to effectively resuscitate individuals in hemorrhagic shock when more conventional blood products are not readily available. METHODS Purpose-bred adult dogs (n = 6) were anesthetized, instrumented, and subjected to hemorrhagic shock (MAP <50 mmHg or 40% blood volume loss). Then each dog was resuscitated with one of five resuscitation products: (1) lactated ringers solution and hetastarch (LRS/heta), (2) canine chilled whole blood (CWB), (3) fresh frozen plasma (FFP) and packed red blood cells (pRBC), (4) canine freeze-dried plasma (FDP) and hemoglobin-based oxygen carrier (HBOC), or (5) HBOC/FDP and canine lyophilized platelets (LyoPLT). Each dog was allowed to recover after the hemorrhage resuscitation event and was then subjected to another hemorrhage event and resuscitated with a different product until each dog was resuscitated with each product. RESULTS At the time when animals were determined to be out of shock as defined by a shock index <1, MAP (mm Hg) values (mean ± standard error) were higher for FFP/pRBC (n = 5, 83.7 ± 4.5) and FDP/HBOC+LyoPLT (n = 4, 87.8. ± 2.1) as compared to WB (n = 4, 66.0 ± 13.1). A transient increase in creatinine was seen in dogs resuscitated with HBOC and FDP. Albumin and base excess increased in dogs resuscitated with HBOC and FDP products compared to LRS/heta and CWB (p < 0.01). CONCLUSION Combinations of shelf-stable blood products compared favorably to canine CWB for resolution of shock. Further research is needed to ascertain the reliability and efficacy of these shelf-stable combinations of products in other models of hemorrhage that include a component of tissue damage as well as naturally occurring trauma. LEVEL OF EVIDENCE This is a Therapeutic/Care management study with Level of Evidence IV.
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Affiliation(s)
| | - Emilee C Venn
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | | | | | - Talli Hogen
- Nora Eccles-Harrison Cardiovascular Research and Training Institute, Salt Lake City, UT
| | - Rebekah Ford
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Nicole Ewer
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Ranger Gunville
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Cali Carroll
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Amy Taylor
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
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Huther A, Edwards TH, Jaramillo EL, Giles JT, Israel SK, Mison M, Ambrosius L, Kaiser T, Hoareau GL. The use of a kaolin-based hemostatic dressing to attenuate bleeding in dogs: A series of 4 cases. J Vet Emerg Crit Care (San Antonio) 2024; 34:166-172. [PMID: 38407539 DOI: 10.1111/vec.13361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To describe the use of a synthetic hemostatic dressing, QuikClot Combat Gauze (QCG), in dogs with bleeding wounds. CASE SERIES SUMMARY Two dogs presented with bleeding traumatic wounds, and QCG was used to achieve hemostasis during stabilization of these dogs. In the other 2 dogs, QCG was used to help attenuate bleeding associated with a surgical procedure. NEW OR UNIQUE INFORMATION PROVIDED While hemostatic dressings have been widely studied and used in human medicine, there is minimal information on the use and efficacy of these hemostatic dressings in veterinary medicine. This case series describes the use of QCG in dogs with hemorrhaging wounds. QCG could be a valuable resource in veterinary emergency and critical care settings.
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Affiliation(s)
- Andrea Huther
- BluePearl Veterinary Specialists of Stone Oak, San Antonio, Texas, USA
| | - Thomas H Edwards
- BluePearl Veterinary Specialists of Stone Oak, San Antonio, Texas, USA
- U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas, USA
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, Tennessee, USA
| | | | - James T Giles
- BluePearl Veterinary Specialists of Stone Oak, San Antonio, Texas, USA
| | - Sarah K Israel
- BluePearl Veterinary Specialists of Stone Oak, San Antonio, Texas, USA
| | - Michael Mison
- College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | | | | | - Guillaume L Hoareau
- School of Medicine, Emergency Medicine, University of Utah, Salt Lake City, Utah, USA
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3
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Silverton NA, Lofgren LR, Kuck K, Stoddard GJ, Johnson R, Ramezani A, Hoareau GL. Near-infrared spectroscopy for kidney oxygen monitoring in a porcine model of hemorrhagic shock, hemodilution, and REBOA. Sci Rep 2024; 14:2646. [PMID: 38302567 PMCID: PMC10834443 DOI: 10.1038/s41598-024-51886-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Acute kidney injury is a common complication of trauma and hemorrhagic shock. In a porcine model of hemorrhagic shock, resuscitative endovascular balloon aortic occlusion (REBOA) and hemodilution, we hypothesized that invasive kidney oxygen concentration measurements would correlate more strongly with noninvasive near infra-red spectroscopy (NIRS) oxygen saturation measurements when cutaneous sensors were placed over the kidney under ultrasound guidance compared to placement over the thigh muscle and subcutaneous tissue. Eight anesthetized swine underwent hemorrhagic shock 4 of which were resuscitated with intravenous fluids prior to the return of shed blood (Hemodilution protocol) and 4 of which underwent REBOA prior to resuscitation and return of shed blood (REBOA protocol). There was a moderate correlation between the NIRS and kidney tissue oxygen measurements (r = 0.61 p < 0.001; r = 0.67 p < 0.001; r = 0.66 p < 0.001for left kidney, right kidney, and thigh NIRS respectively). When the animals were separated by protocol, the Hemodilution group showed a weak or nonsignificant correlation between NIRS and kidney tissue oxygen measurements (r = 0.10 p < 0.001; r = 0.01 p = 0.1007; r = 0.28 p < 0.001 for left kidney, right kidney, and thigh NIRS respectively). This contrasts with the REBOA group, where left and right kidney as well as thigh NIRS were moderately correlated with kidney tissue oxygen (r = 0.71 p < 0.001; r = 0.74 p < 0.001; r = 0.70 p < 0.001; for left kidney, right kidney, and thigh NIRS respectively). There was a strong correlation between both kidney NIRS signals and thigh NIRS measurements (r = 0.85 p < 0.001; r = 0.88 p < 0.001;for left kidney vs thigh and right kidney vs thigh respectively). There was also a strong correlation between left and right kidney NIRS (r = 0.90 p < 0.001). These relationships were maintained regardless of the resuscitation protocol. These results suggest that kidney NIRS measurements were more closely related to thigh NIRS measurements than invasive kidney tissue oxygen concentration.
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Affiliation(s)
- Natalie A Silverton
- Department of Anesthesiology, University of Utah, Helix Building 5050, 30N Mario Capecchi Dr., Salt Lake City, UT, 84132, USA.
- Geriatric Research, Education and Clinical Center, VA Medical Center, 500 Foothill Dr, Salt Lake City, UT, 84148, USA.
| | - Lars R Lofgren
- Department of Anesthesiology, University of Utah, Helix Building 5050, 30N Mario Capecchi Dr., Salt Lake City, UT, 84132, USA
| | - Kai Kuck
- Department of Anesthesiology, University of Utah, Helix Building 5050, 30N Mario Capecchi Dr., Salt Lake City, UT, 84132, USA
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Rm 1N433, Salt Lake City, UT, 84132, USA
| | - Russel Johnson
- Department of Emergency Medicine, Helix Building 5050, 30 N Mario Capecchi, Room 2S240, Level 2, South, Salt Lake City, UT, 84132, USA
| | - Ali Ramezani
- Department of Anesthesiology, University of Utah, Helix Building 5050, 30N Mario Capecchi Dr., Salt Lake City, UT, 84132, USA
| | - Guillaume L Hoareau
- Department of Emergency Medicine, Nora Eccles Harrison Cardiovascular Research and Training Institute, Helix Building 5050, 30 N Mario Capecchi, Room 2S240, Level 2, South, Salt Lake City, UT, 84132, USA
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Haugland H, Gamberini L, Hoareau GL, Haenggi M, Greif R, Brede JR. Resuscitative endovascular balloon occlusion of the aorta in out-of-hospital cardiac arrest - A Delphi consensus study for uniform data collection. Resusc Plus 2023; 16:100485. [PMID: 37859631 PMCID: PMC10583171 DOI: 10.1016/j.resplu.2023.100485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
Background Evolving research on resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct treatment for out-of-hospital cardiac arrest mandates uniform recording and reporting of data. A consensus on which variables need to be collected may enable comparing and merging data from different studies. We aimed to establish a standard set of variables to be collected and reported in future REBOA studies in out-of-hospital cardiac arrest. Methods A four-round stepwise Delphi consensus process first asked experts to propose without restraint variables for future REBOA research in out-of-hospital cardiac arrest. The experts then reviewed the variables on a 5-point Likert scale and ≥75% agreement was defined as consensus. First authors of published papers on REBOA in out-of-hospital cardiac arrest over the last five years were invited to join the expert panel. Results The data were collected between May 2022 and December 2022. A total of 28 experts out of 34 primarily invited completed the Delphi process, which developed a set of 31 variables that might be considered as a supplement to the Utstein style reporting of research in out-of-hospital cardiac arrest. Conclusions This Delphi consensus process suggested 31 variables that enable future uniform reporting of REBOA in out-of-hospital cardiac arrest.
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Affiliation(s)
- Helge Haugland
- St. Olav’s University Hospital, Trondheim, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | | | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Robert Greif
- University of Bern, Bern Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
- ERC ResearchNet, Niel, Belgium
| | - Jostein Rødseth Brede
- St. Olav’s University Hospital, Trondheim, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
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Hilgart DR, Iversen MM, Peters AY, Zabriskie MS, Hoareau GL, Vapniarsky N, Clark GA, Shah LM, Rieke V. Non-invasive central nervous system assessment of a porcine model of neuropathic pain demonstrates increased latency of somatosensory-evoked potentials. J Neurosci Methods 2023; 396:109934. [PMID: 37524248 PMCID: PMC10530261 DOI: 10.1016/j.jneumeth.2023.109934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/01/2023] [Accepted: 07/28/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND The study of chronic pain and its treatments requires a robust animal model with objective and quantifiable metrics. Porcine neuropathic pain models have been assessed with peripheral pain recordings and behavioral responses, but thus far central nervous system electrophysiology has not been investigated. This work aimed to record non-invasive, somatosensory-evoked potentials (SEPs) via electroencephalography in order to quantitatively assess chronic neuropathic pain induced in a porcine model. NEW METHOD Peripheral neuritis trauma (PNT) was induced unilaterally in the common peroneal nerve of domestic farm pigs, with the contralateral leg serving as the control for each animal. SEPs were generated by stimulation of the peripheral nerves distal to the PNT and were recorded non-invasively using transcranial electroencephalography (EEG). The P30 wave of the SEP was analyzed for latency changes. RESULTS P30 SEPs were successfully recorded with non-invasive EEG. PNT resulted in significantly longer P30 SEP latencies (p < 0.01 [n = 8]) with a median latency increase of 14.3 [IQR 5.0 - 17.5] ms. Histological results confirmed perineural inflammatory response and nerve damage around the PNT nerves. COMPARISON WITH EXISTING METHOD(S) Control P30 SEPs were similar in latency and amplitude to those previously recorded invasively in healthy pigs. Non-invasive recordings have numerous advantages over invasive measures. CONCLUSIONS P30 SEP latency can serve as a quantifiable neurological measure that reflects central nervous system processing in a porcine model of chronic pain. Advancing the development of a porcine chronic pain model will facilitate the translation of experimental therapies into human clinical trials.
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Affiliation(s)
- David R Hilgart
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Marta M Iversen
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Angela Y Peters
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Matthew S Zabriskie
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Guillaume L Hoareau
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Natalia Vapniarsky
- Department of Pathology Microbiology and Immunology, University of California Davis, Davis, CA, USA
| | - Gregory A Clark
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Lubdha M Shah
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Viola Rieke
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA.
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6
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Khan MS, Smego D, Ishidoya Y, Hirahara AM, Offei E, Ruiz Castillo MS, Gharbia O, Li H, Palatinus JA, Krueger L, Hong T, Hoareau GL, Ranjan R, Selzman CH, Shaw RM, Dosdall DJ. A canine model of chronic ischemic heart failure. Am J Physiol Heart Circ Physiol 2023; 324:H751-H761. [PMID: 36961487 PMCID: PMC10151054 DOI: 10.1152/ajpheart.00647.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023]
Abstract
Preclinical large animal models of chronic heart failure (HF) are crucial to both understanding pathological remodeling and translating fundamental discoveries into novel therapeutics for HF. Canine models of ischemic cardiomyopathy are historically limited by either high early mortality or failure to develop chronic heart failure. Twenty-nine healthy adult dogs (30 ± 4 kg, 15/29 male) underwent thoracotomy followed by one of three types of left anterior descending (LAD) coronary artery ligation procedures: group 1 (n = 4) (simple LAD: proximal and distal LAD ligation); group 2 (n = 14) (simple LAD plus lateral wall including ligation of the distal first diagonal and proximal first obtuse marginal); and group 3 (n = 11) (total LAD devascularization or TLD: simple LAD plus ligation of proximal LAD branches to both the right and left ventricles). Dogs were followed until chronic severe HF developed defined as left ventricular ejection fraction (LVEF) < 40% and NH2-terminal-prohormone B-type natriuretic peptide (NT-proBNP) > 900 pmol/L. Overall early survival (48-h postligation) in 29 dogs was 83% and the survival rate at postligation 5 wk was 69%. Groups 1 and 2 had 100% and 71% early survival, respectively, yet only a 50% success rate of developing chronic HF. Group 3 had excellent survival at postligation 48 h (91%) and a 100% success in the development of chronic ischemic HF. The TLD approach, which limits full LAD and collateral flow to its perfusion bed, provides excellent early survival and reliable development of chronic ischemic HF in canine hearts.NEW & NOTEWORTHY The novel total left anterior descending devascularization (TLD) approach in a canine ischemic heart failure model limits collateral flow in the ischemic zone and provides excellent early survival and repeatable development of chronic ischemic heart failure in the canine heart. This work provides a consistent large animal model for investigating heart failure mechanisms and testing novel therapeutics.
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Affiliation(s)
- Muhammad S Khan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
| | - Douglas Smego
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah, Salt Lake City, Utah, United States
| | - Yuki Ishidoya
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah, Salt Lake City, Utah, United States
| | - Annie M Hirahara
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, Utah, United States
| | - Emmanuel Offei
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, Utah, United States
| | - Martha S Ruiz Castillo
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, Utah, United States
| | - Omar Gharbia
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
| | - Hui Li
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah, Salt Lake City, Utah, United States
| | - Joseph A Palatinus
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah, Salt Lake City, Utah, United States
| | - Lauren Krueger
- Office of Comparative Medicine, The University of Utah, Salt Lake City, Utah, United States
| | - TingTing Hong
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Utah, Salt Lake City, Utah, United States
| | - Guillaume L Hoareau
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Department of Emergency Medicine, The University of Utah, Salt Lake City, Utah, United States
| | - Ravi Ranjan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah, Salt Lake City, Utah, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, Utah, United States
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah, Salt Lake City, Utah, United States
| | - Robin M Shaw
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah, Salt Lake City, Utah, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, Utah, United States
| | - Derek J Dosdall
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah, Salt Lake City, Utah, United States
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah, Salt Lake City, Utah, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah, Salt Lake City, Utah, United States
- Department of Biomedical Engineering, The University of Utah, Salt Lake City, Utah, United States
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Patel N, Johnson MA, Vapniarsky N, Van Brocklin MW, Williams TK, Youngquist ST, Ford R, Ewer N, Neff LP, Hoareau GL. Elamipretide mitigates ischemia-reperfusion injury in a swine model of hemorrhagic shock. Sci Rep 2023; 13:4496. [PMID: 36934127 PMCID: PMC10024723 DOI: 10.1038/s41598-023-31374-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/10/2023] [Indexed: 03/20/2023] Open
Abstract
ischemia-reperfusion injury (IRI) after hemorrhage is potentiated by aortic occlusion or resuscitative endovascular balloon occlusion of the aorta (REBOA). Given the central role of mitochondrial injury in shock, we hypothesized that Elamipretide, a peptide that protects mitochondria, would mitigate IRI after hemorrhagic shock and REBOA. Twelve pigs were subjected to hemorrhagic shock and 45 min of REBOA. After 25 min of REBOA, animals received either saline or Elamipretide. Animals were transfused with autologous blood during balloon deflation, and pigs were resuscitated with isotonic crystalloids and norepinephrine for 4.25 h. Elamipretide-treated animals required less crystalloids than the controls (62.5 [50-90] and 25 [5-30] mL/kg, respectively), but similar amounts of norepinephrine (24.7 [8.6-39.3] and 9.7 [2.1-12.5] mcg/kg, respectively). Treatment animals had a significant reduction in serum creatinine (control: 2.7 [2.6-2.8]; Elamipretide: 2.4 [2.4-2.5] mg/dL; p = 0.04), troponin (control: 3.20 [2.14-5.47] ng/mL, Elamipretide: 0.22 [0.1-1.91] ng/mL; p = 0.03), and interleukin-6 concentrations at the end of the study. There were no differences in final plasma lactate concentration. Elamipretide reduced fluid requirements and protected the kidney and heart after profound IRI. Further understanding the subcellular consequences of REBOA and mitochondrial rescue will open new therapeutic avenues for patients suffering from IRI after hemorrhage.
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Affiliation(s)
- N Patel
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - M A Johnson
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - N Vapniarsky
- Department of Pathology, Microbiology, and Immunology, University of California-Davis, Davis, CA, USA
| | - M W Van Brocklin
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - T K Williams
- Department of Vascular/Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - S T Youngquist
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - R Ford
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - N Ewer
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - L P Neff
- Department of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - G L Hoareau
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
- Nora Eccles-Harrison Cardiovascular Research and Training Institute, Salt Lake City, UT, USA.
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Patel NTP, Gaffley M, Leblanc MJR, Lane MR, Hoareau GL, Johnson MA, Jordan JE, Neff LP, Williams TK. Endovascular Perfusion Augmentation After Resuscitative Endovascular Balloon Occlusion of the Aorta Improves Renal Perfusion and Decreases Vasopressors. J Surg Res 2022; 279:712-721. [PMID: 35933789 DOI: 10.1016/j.jss.2022.06.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/09/2022] [Accepted: 06/30/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) causes a severe ischemia-reperfusion injury. Endovascular Perfusion Augmentation for Critical Care (EPACC) has emerged as a hemodynamic/mechanical adjunct to vasopressors and crystalloid for the treatment of post-REBOA ischemia-reperfusion injury. The objective of the study is to examine the impact of EPACC as a tool for a wean from complete REBOA compared to standard resuscitation techniques. METHODS Nine swine underwent anesthesia and then a controlled 30% blood volume hemorrhage with 30 min of supraceliac total aortic occlusion to create an ischemia-reperfusion injury. Animals were randomized to standardized critical care (SCC) or 90 min of EPACC followed by SCC. The critical care phase lasted 270 min after injury. Hemodynamic markers and laboratory values of ischemia were recorded. RESULTS During the first 90 min the intervention phase SCC spent 60% (54%-73%) and EPACC spent 91% (88%-92%) of the time avoiding proximal hypotension (<60 mm Hg), P = 0.03. There was also a statistically significant decrease in cumulative norepinephrine dose at the end of the experiment between SCC (80.89 mcg/kg) versus EPACC (22.03 mcg/kg), P = 0.03. Renal artery flow during EPACC was similar compared to SCC during EPACC, P = 0.19. But during the last hour of the experiment (after removal of aortic balloon) the renal artery flow in EPACC (2.9 mL/kg/min) was statistically significantly increased compared to SCC (1.57 mL/min/kg), P = 0.03. There was a statistically significant decrease in terminal creatinine in the EPACC (1.7 mg/dL) compared to SCC (2.1 mg/dL), P = 0.03. CONCLUSIONS The 90 min of EPACC as a weaning adjunct in the setting of a severe ischemia-reperfusion injury after complete supraceliac REBOA provides improved renal flow with improvement in terminal creatinine compared to SCC with stabilized proximal hemodynamics and decreased vasopressor dose.
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Affiliation(s)
- Nathan T P Patel
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
| | - Michaela Gaffley
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Mathias J R Leblanc
- Division of Animal Resources Program, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Magan R Lane
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | | | - M Austin Johnson
- Division of Emergency Medicine, University of Utah, Salt Lake City, Utah
| | - James E Jordan
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Lucas P Neff
- Department of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Timothy K Williams
- Department of Vascular/Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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9
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Lofgren LR, Hoareau GL, Kuck K, Silverton NA. Noninvasive and Invasive Renal Hypoxia Monitoring in a Porcine Model of Hemorrhagic Shock. J Vis Exp 2022:10.3791/64461. [PMID: 36373937 PMCID: PMC10044407 DOI: 10.3791/64461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Up to 50% of patients with trauma develop acute kidney injury (AKI), in part due to poor renal perfusion after severe blood loss. AKI is currently diagnosed based on a change in serum creatinine concentration from baseline or prolonged periods of decreased urine output. Unfortunately, baseline serum creatinine concentration data is unavailable in most patients with trauma, and current estimation methods are inaccurate. In addition, serum creatinine concentration may not change until 24-48 h after the injury. Lastly, oliguria must persist for a minimum of 6 h to diagnose AKI, making it impractical for early diagnosis. AKI diagnostic approaches available today are not useful for predicting risk during the resuscitation of patients with trauma. Studies suggest that urinary partial pressure of oxygen (PuO2) may be useful for assessing renal hypoxia. A monitor that connects the urinary catheter and the urine collection bag was developed to measure PuO2 noninvasively. The device incorporates an optical oxygen sensor that estimates PuO2 based on luminescence quenching principles. In addition, the device measures urinary flow and temperature, the latter to adjust for confounding effects of temperature changes. Urinary flow is measured to compensate for the effects of oxygen ingress during periods of low urine flow. This article describes a porcine model of hemorrhagic shock to study the relationship between noninvasive PuO2, renal hypoxia, and AKI development. A key element of the model is the ultrasound-guided surgical placement in the renal medulla of an oxygen probe, which is based on an unsheathed optical microfiber. PuO2 will also be measured in the bladder and compared to the kidney and noninvasive PuO2 measurements. This model can be used to test PuO2 as an early marker of AKI and assess PuO2 as a resuscitative endpoint after hemorrhage that is indicative of end-organ rather than systemic oxygenation.
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Affiliation(s)
- Lars R Lofgren
- Department of Biomedical Engineering, University of Utah;
| | - Guillaume L Hoareau
- Department of Emergency Medicine, University of Utah; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah
| | - Kai Kuck
- Department of Biomedical Engineering, University of Utah; Department of Anesthesiology, University of Utah
| | - Natalie A Silverton
- Department of Anesthesiology, University of Utah; Geriatric Research, Education, and Clinical Centre, VAMC
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10
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Nowadly CD, Johnson MA, Youngquist ST, Williams TK, Neff LP, Hoareau GL. Automated aortic endovascular balloon volume titration prevents re-arrest immediately after return of spontaneous circulation in a swine model of nontraumatic cardiac arrest. Resusc Plus 2022; 10:100239. [PMID: 35542691 PMCID: PMC9079240 DOI: 10.1016/j.resplu.2022.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Endovascular aortic occlusion as an adjunct to cardiopulmonary resuscitation (CPR) for non-traumatic cardiac arrest is gaining interest. In a recent clinical trial, return of spontaneous circulation (ROSC) was achieved despite prolonged no-flow times. However, 66% of patients re-arrested upon balloon deflation. We aimed to determine if automated titration of endovascular balloon volume following ROSC can augment diastolic blood pressure (DBP) to prevent re-arrest. Methods Twenty swine were anesthetized and placed into ventricular fibrillation (VF). Following 7 minutes of no-flow VF and 5 minutes of mechanical CPR, animals were subjected to complete aortic occlusion to adjunct CPR. Upon ROSC, the balloon was either deflated steadily over 5 minutes (control) or underwent automated, dynamic adjustments to maintain a DBP of 60 mmHg (Endovascular Variable Aortic Control, EVAC). Results ROSC was obtained in ten animals (5 EVAC, 5 REBOA). Sixty percent (3/5) of control animals rearrested while none of the EVAC animals rearrested (p = 0.038). Animals in the EVAC group spent a significantly higher proportion of the post-ROSC period with a DBP > 60 mmHg [median (IQR)] [control 79.7 (72.5–86.0)%; EVAC 97.7 (90.8–99.7)%, p = 0.047]. The EVAC group had a statistically significant reduction in arterial lactate concentration [7.98 (7.4–8.16) mmol/L] compared to control [9.93 (8.86–10.45) mmol/L, p = 0.047]. There were no statistical differences between the two groups in the amount of adrenaline (epinephrine) required. Conclusion In our swine model of cardiac arrest, automated aortic endovascular balloon titration improved DBP and prevented re-arrest in the first 20 minutes after ROSC.
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Affiliation(s)
- Craig D. Nowadly
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States
| | - M. Austin Johnson
- Department of Emergency Medicine, University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - Scott T. Youngquist
- Department of Emergency Medicine, University of Utah, School of Medicine, Salt Lake City, UT, United States
- The Salt Lake City Fire Department, Salt Lake City, UT, United States
| | - Timothy K. Williams
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Lucas P. Neff
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Guillaume L. Hoareau
- Department of Emergency Medicine, University of Utah, School of Medicine, Salt Lake City, UT, United States
- The Nora Eccles-Harrison Cardiovascular and Research Training Institute, University of Utah, School of Medicine, Salt Lake City, Utah, United States
- Corresponding author at: University of Utah Health, Department of Emergency Medicine, 30 N. 1900 E. Room 1C26, Salt Lake City, UT 84132, United States.
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11
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deLaforcade A, Bacek L, Blais M, Boyd C, Brainard BM, Chan DL, Cortellini S, Goggs R, Hoareau GL, Koenigshof A, Li R, Lynch A, Ralph A, Rozanski E, Sharp CR. 2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 1- Defining populations at risk. J Vet Emerg Crit Care (San Antonio) 2022; 32:289-314. [PMID: 35499966 PMCID: PMC9322658 DOI: 10.1111/vec.13204] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To expand the number of conditions and interventions explored for their associations with thrombosis in the veterinary literature and to provide the basis for prescribing recommendations. DESIGN A population exposure comparison outcome format was used to represent patient, exposure, comparison, and outcome. Population Exposure Comparison Outcome questions were distributed to worksheet authors who performed comprehensive searches, summarized the evidence, and created guideline recommendations that were reviewed by domain chairs. The revised guidelines then underwent the Delphi survey process to reach consensus on the final guidelines. Diseases evaluated in this iteration included heartworm disease (dogs and cats), immune-mediated hemolytic anemia (cats), protein-losing nephropathy (cats), protein-losing enteropathy (dogs and cats), sepsis (cats), hyperadrenocorticism (cats), liver disease (dogs), congenital portosystemic shunts (dogs and cats) and the following interventions: IV catheters (dogs and cats), arterial catheters (dogs and cats), vascular access ports (dogs and cats), extracorporeal circuits (dogs and cats) and transvenous pacemakers (dogs and cats). RESULTS Of the diseases evaluated in this iteration, a high risk for thrombosis was defined as heartworm disease or protein-losing enteropathy. Low risk for thrombosis was defined as dogs with liver disease, cats with immune-mediated hemolytic anemia, protein-losing nephropathy, sepsis, or hyperadrenocorticism. CONCLUSIONS Associations with thrombosis are outlined for various conditions and interventions and provide the basis for management recommendations. Numerous knowledge gaps were identified that represent opportunities for future studies.
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Affiliation(s)
- Armelle deLaforcade
- Department of Clinical Sciences, Cummings School of Veterinary MedicineTufts UniversityNorth GraftonMassachusettsUSA
| | - Lenore Bacek
- Bluepearl Specialty and Emergency Pet HospitalTampaFloridaUSA
| | - Marie‐Claude Blais
- Department of Clinical SciencesUniversity of MontrealSaint‐HyacintheQCCanada
| | - Corrin Boyd
- School of Veterinary MedicineMurdoch UniversityMurdochAustralia
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, Clinical SciencesUniversity of GeorgiaAthensGeorgiaUSA
| | - Daniel L. Chan
- Department of Clinical Science and ServicesThe Royal Veterinary CollegeLondonUK
| | - Stefano Cortellini
- Department of Clinical Science and ServicesThe Royal Veterinary CollegeLondonUK
| | - Robert Goggs
- Department of Clinical SciencesCornell University College of Veterinary MedicineIthacaNew YorkUSA
| | | | - Amy Koenigshof
- Department of Emergency CareTwo by Two Animal HospitalBerrien SpringsMichiganUSA
| | - Ron Li
- Department of Veterinary Surgical and Radiological SciencesSchool of Veterinary MedicineUniversity of California DavisDavisCaliforniaUSA
| | - Alex Lynch
- Department of Clinical SciencesNC State College of Veterinary MedicineRaleighNorth CarolinaUSA
| | | | - Elizabeth Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary MedicineTufts UniversityNorth GraftonMassachusettsUSA
| | - Claire R Sharp
- School of Veterinary MedicineMurdoch UniversityMurdochAustralia
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12
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Hoareau GL, Peters A, Hilgart D, Iversen M, Clark G, Zabriskie M, Rieke V, Floyd C, Shah L. Feasibility of non-invasive recording of somatosensory evoked potential in pigs. Lab Anim Res 2022; 38:9. [PMID: 35331342 PMCID: PMC8943992 DOI: 10.1186/s42826-022-00118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/12/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Non-invasive measurement of somatosensory-evoked potentials (SEP) in a large animal model is important to translational cognitive research. We sought to develop a methodology for neurophysiological recording via a transcranial electroencephalography (EEG) cap under an effective sedative regimen with dexmedetomidine, midazolam, and butorphanol that will produce sedation instead of anesthesia while not compromising data quality. RESULTS Pigs received intramuscular dexmedetomidine, midazolam, and butorphanol for SEP assessment with peroneal nerve stimulation. Semi-quantitative sedation assessment was performed after the animal was sufficiently sedated and 30 min later, during the transcranial SEP recording. SEP data were analyzed with commercial software. Binary qualitative analysis of the recording was categorized by an experienced neurophysiologist. All four animals had adequate surface SEP recordings. Animals received 43 [21-47] mcg/kg of dexmedetomidine, 0.3 [0.2-0.3] mg/kg of midazolam, and 0.3 [0.3-0.3] mg/kg of butorphanol IM. All treatments resulted in moderate to deep sedation (Baseline median sedation score 11.5 [11-12]; median score at 30 min: 11.5 [10.5-12]). Heart rate (median [range]) (55 [49-71] beats per minute), respiratory rate (24 [21-30] breaths per minute), and hemoglobin oxygen saturation (99 [98-100]%) and body temperature (37.7 [37.4-37.9] °C) remained within clinically acceptable ranges. There were no undesirable recovery incidents. CONCLUSIONS In this pilot study, we demonstrate the feasibility of SEP recording via a transcranial EEG cap under an effective sedative regimen in pigs. Our approach will expand the use of a large animal model in neurotranslational research.
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Affiliation(s)
- Guillaume L Hoareau
- Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City, UT, USA.
| | - Angela Peters
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - David Hilgart
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Marta Iversen
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Gregory Clark
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Matthew Zabriskie
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Viola Rieke
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Candace Floyd
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Lubdha Shah
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
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13
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Sommakia S, Almaw NH, Lee SH, Ramadurai DKA, Taleb I, Kyriakopoulos CP, Stubben CJ, Ling J, Campbell RA, Alharethi RA, Caine WT, Navankasattusas S, Hoareau GL, Abraham AE, Fang JC, Selzman CH, Drakos SG, Chaudhuri D. FGF21 (Fibroblast Growth Factor 21) Defines a Potential Cardiohepatic Signaling Circuit in End-Stage Heart Failure. Circ Heart Fail 2022; 15:e008910. [PMID: 34865514 PMCID: PMC8930477 DOI: 10.1161/circheartfailure.121.008910] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Extrinsic control of cardiomyocyte metabolism is poorly understood in heart failure (HF). FGF21 (Fibroblast growth factor 21), a hormonal regulator of metabolism produced mainly in the liver and adipose tissue, is a prime candidate for such signaling. METHODS To investigate this further, we examined blood and tissue obtained from human subjects with end-stage HF with reduced ejection fraction at the time of left ventricular assist device implantation and correlated serum FGF21 levels with cardiac gene expression, immunohistochemistry, and clinical parameters. RESULTS Circulating FGF21 levels were substantially elevated in HF with reduced ejection fraction, compared with healthy subjects (HF with reduced ejection fraction: 834.4 [95% CI, 628.4-1040.3] pg/mL, n=40; controls: 146.0 [86.3-205.7] pg/mL, n=20, P=1.9×10-5). There was clear FGF21 staining in diseased cardiomyocytes, and circulating FGF21 levels negatively correlated with the expression of cardiac genes involved in ketone metabolism, consistent with cardiac FGF21 signaling. FGF21 gene expression was very low in failing and nonfailing hearts, suggesting extracardiac production of the circulating hormone. Circulating FGF21 levels were correlated with BNP (B-type natriuretic peptide) and total bilirubin, markers of chronic cardiac and hepatic congestion. CONCLUSIONS Circulating FGF21 levels are elevated in HF with reduced ejection fraction and appear to bind to the heart. The liver is likely the main extracardiac source. This supports a model of hepatic FGF21 communication to diseased cardiomyocytes, defining a potential cardiohepatic signaling circuit in human HF.
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Affiliation(s)
- Salah Sommakia
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Naredos H. Almaw
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Sandra H. Lee
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Dinesh K. A. Ramadurai
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Iosif Taleb
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Christos P. Kyriakopoulos
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Chris J. Stubben
- Bioinformatics Shared Resource, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112
| | - Jing Ling
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Robert A. Campbell
- Department of Internal Medicine, Division of General Medicine, Program in Molecular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Rami A. Alharethi
- U.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant Program: University of Utah Healthcare and School of Medicine, Intermountain Medical Center, Salt Lake Veterans Affairs Health Care System, Salt Lake City, UT
| | - William T. Caine
- U.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant Program: University of Utah Healthcare and School of Medicine, Intermountain Medical Center, Salt Lake Veterans Affairs Health Care System, Salt Lake City, UT
| | - Sutip Navankasattusas
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Guillaume L. Hoareau
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Department of Surgery, Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Anu E. Abraham
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT
| | - James C. Fang
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT
| | - Craig H. Selzman
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- U.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant Program: University of Utah Healthcare and School of Medicine, Intermountain Medical Center, Salt Lake Veterans Affairs Health Care System, Salt Lake City, UT
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT
| | - Stavros G. Drakos
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT
| | - Dipayan Chaudhuri
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT
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14
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Odunayo A, Alwood A, Asokan V, Balakrishnan A, Berkowitz S, Buckley G, Chih A, Claus K, Cottam E, Gonzalez A, Hoareau GL, Holowaychuk M, Johnson P, Kielb J, Ngwenyama T, Pardo M, Rutter C, Sharpe S, Whitehead K. Our quest for creating a space that is welcoming to all: A commentary from the American College of Veterinary Emergency and Critical Care Diversity, Equity, and Inclusion Committee. J Vet Emerg Crit Care (San Antonio) 2022; 32:165-167. [DOI: 10.1111/vec.13190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Adesola Odunayo
- Department of Small Animal Clinical Sciences University of Florida College of Veterinary Medicine Gainesville Florida USA
| | - Amy Alwood
- Department of Critical Care BluePearl Specialty and Emergency Pet Hospital Newark Delaware USA
| | - Vibha Asokan
- Heart of Texas Veterinary Specialty Center Round Rock Texas USA
| | | | | | - Gareth Buckley
- Department of Small Animal Clinical Sciences University of Florida College of Veterinary Medicine Gainesville Florida USA
| | - Annie Chih
- Animal Medical Center of Seattle Shoreline Washington USA
| | | | - Emily Cottam
- Veterinary Medical Center of Central New York East Syracuse New York USA
| | - Anthony Gonzalez
- Cornell University Veterinary Specialists Stamford Connecticut USA
| | - Guillaume L. Hoareau
- Department of Emergency Medicine University of Utah Health Salt Lake City Utah USA
| | - Marie Holowaychuk
- Veterinary Specialist and Wellbeing Advocate Reviving Vet Med Calgary Alberta Canada
| | - Paula Johnson
- Department of Veterinary Clinical Sciences Purdue University College of Veterinary Medicine West Lafayette Indiana USA
| | - Jessica Kielb
- BluePearl Pet Hospital Philadelphia Pennsylvania USA
| | - Thandeka Ngwenyama
- Department of Clinical Sciences Oregon State University Corvallis Oregon USA
| | - Mariana Pardo
- Veterinary Emergency Group White Plains New York USA
| | - Christine Rutter
- Department of Clinical Sciences Texas A&M University College Station Texas USA
| | | | - KimMi Whitehead
- Intensivets and Intellivets, LLC Philadelphia Pennsylvania USA
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15
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Hoareau GL, Beyer CA, Caples CA, Spruce MW, Kevin Grayson J, Neff LP, Williams TK, Johnson MA. Automated Partial Versus Complete Resuscitative Endovascular Balloon Occlusion of the Aorta for the Management of Hemorrhagic Shock in a Pig Model of Polytrauma: a Randomized Controlled Pilot Study. Mil Med 2021; 185:e1923-e1930. [PMID: 32830262 DOI: 10.1093/milmed/usaa217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/04/2020] [Accepted: 07/17/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Endovascular variable aortic control (EVAC) is an automated partial resuscitative endovascular balloon occlusion of the aorta (REBOA) platform designed to mitigate the deleterious effects of complete REBOA. Long-term experiments are needed to assess potential benefits. The feasibility of a 24-hour experiment in a complex large animal trauma model remains unknown. MATERIALS AND METHODS Anesthetized swine were subjected to controlled hemorrhage, blunt thoracic trauma, and tibial fractures. Animals were then randomized (N = 3/group) to control (No balloon support), 90 minutes of complete supraceliac REBOA, or 10 minutes of supraceliac REBOA followed by 80 minutes of EVAC. One hundred ten minutes after injury, animals were resuscitated with shed blood, the REBOA catheter was removed. Automated critical care under general anesthesia was maintained for 24 hours. RESULTS Animals in the control and EVAC groups survived to the end of the experiment. Animals in the REBOA group survived for 120, 130, and 660 minutes, respectively. Animals in the EVAC group displayed similar mean arterial pressure and plasma lactate concentration as the control group by the end of the experiment. Histologic analysis suggested myocardial injury in the REBOA group when compared with controls. CONCLUSIONS This study demonstrates the feasibility of intermediate-term experiments in a complex swine model of polytrauma with 90 minutes of REBOA. EVAC may be associated with improved survival at 24 hours when compared with complete REBOA. EVAC resulted in normalized physiology after 24 hours, suggesting that prolonged partial occlusion is possible. Longer studies evaluating partial REBOA strategies are needed.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.,Division of Emergency Medicine, 30N 1900E, Room 1C26, Salt Lake City, UT84132
| | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817
| | - Connor A Caples
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817
| | - Marguerite W Spruce
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535
| | - Lucas P Neff
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.,Department of Pediatric Surgery, Wake Forest Baptist Health, Winston-Salem, NC 1 Medical Center Blvd, Winston-Salem, NC 27157
| | - Timothy K Williams
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.,Department of Vascular and Endovascular Surgery, Wake Forest Baptist Health, Winston-Salem, NC 1 Medical Center Blvd, Winston-Salem, NC 27157
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535.,Division of Emergency Medicine, 30N 1900E, Room 1C26, Salt Lake City, UT84132
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16
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Silverton NA, Hall IE, Melendez NP, Harris B, Harley JS, Parry SR, Lofgren LR, Stoddard GJ, Hoareau GL, Kuck K. Intraoperative Urinary Biomarkers and Acute Kidney Injury After Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:1691-1700. [PMID: 33549487 DOI: 10.1053/j.jvca.2020.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the association of intraoperative urinary biomarker excretion during cardiac surgery and the subsequent development of acute kidney injury (AKI). DESIGN Prospective, nonrandomized, observational study. SETTING Single tertiary-level, university-affiliated hospital. PARTICIPANTS Ninety patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Urinary samples were collected every 30 minutes intraoperatively and then at four, 12, and 24 hours after CPB. Samples were measured for interleukin 18 (IL-18), kidney injury molecule-1 (KIM1), and creatinine concentrations. Urinary biomarker excretion (raw and indexed to creatinine) for four intraoperative and three postoperative points were compared between patients with and those without subsequent AKI defined by increased serum creatinine concentration ≥0.3 mg/dL within the first 48 hours or ≥1.5 times baseline within seven days. Raw and indexed median IL-18 values were similar between AKI groups at all intraoperative points, but became significantly different at 12 hours after CPB. Raw and indexed median KIM1 values were significantly different between AKI groups at multiple intraoperative points and at four and 12 hours after CPB. During intraoperative and postoperative points, patients in the fourth quartile of KIM1 excretion had greater AKI incidence and longer intensive care and hospital lengths of stay than those in the first quartile. Only postoperatively did the differences in these outcomes between the fourth and first quartile of IL-18 excretion occur. CONCLUSIONS Intraoperative KIM1 but not IL-18 excretion was associated with postoperative development of AKI.
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Affiliation(s)
| | - Isaac E Hall
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Utah, School of Medicine, Salt Lake City, UT
| | | | - Brad Harris
- Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, UT
| | - Jackson S Harley
- Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, UT
| | - Samuel R Parry
- Department of Statistics, Brigham Young University, Provo, UT
| | - Lars R Lofgren
- Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, UT
| | - Gregory J Stoddard
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Guillaume L Hoareau
- Department of Surgery, Division of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Kai Kuck
- Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, UT
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17
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Abstract
Fluids are a vital tool in the armament of acute care clinicians in both civilian and military resuscitation. We now better understand complications from inappropriate resuscitation with currently available fluids; however, fluid resuscitation undeniably remains a life-saving intervention. Military research has driven the most significant advances in the field of fluid resuscitation and is currently leading the search for the fluids of the future. The veterinary community, much like our civilian human counterparts, should expect the fluid of the future to be the fruit of military research. The fluids of the future not only are expected to improve patient outcomes but also be field expedient. Those fluids should be compatible with military environments or natural disaster environments. For decades, military personnel and disaster responders have faced the peculiar demands of austere environments, prolonged field care, and delayed evacuation. Large scale natural disasters present field limitations often similar to those encountered in the battlefield. The fluids of the future should, therefore, have a long shelf-life, a small footprint, and be resistant to large temperature swings, for instance. Traumatic brain injury and hemorrhagic shock are the leading causes of preventable death for military casualties and a significant burden in civilian populations. The military and civilian health systems are focusing efforts on field-expedient fluids that will be specifically relevant for the management of those conditions. Fluids are expected to be compatible with blood products, increase oxygen-carrying capabilities, promote hemostasis, and be easy to administer in the prehospital setting, to match the broad spectrum of current acute care challenges, such as sepsis and severe systemic inflammation. This article will review historical military and civilian contributions to current resuscitation strategies, describe the expectations for the fluids of the future, and describe select ongoing research efforts with a review of current animal data.
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Affiliation(s)
- Thomas H. Edwards
- US Army Institute of Surgical Research, San Antonio, TX, United States
| | - Guillaume L. Hoareau
- Emergency Medicine, School of Medicine, University of Utah, Salt Lake City, UT, United States
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18
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Beyer CA, Hoareau GL, Kashtan HW, Wishy AM, Caples C, Spruce M, Grayson JK, Neff LP, Williams TK, Johnson MA. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a swine model of hemorrhagic shock and blunt thoracic injury. Eur J Trauma Emerg Surg 2020; 46:1357-1366. [PMID: 31576422 DOI: 10.1007/s00068-019-01185-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/08/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE While resuscitative endovascular balloon occlusion of the aorta (REBOA) is contraindicated in patients with aortic injuries, this technique may benefit poly-trauma patients with less extreme thoracic injuries. The purpose of this study was to characterize the effects of thoracic injury on hemodynamics during REBOA and the changes in pulmonary contusion over time in a swine model. METHODS Twelve swine were anesthetized, instrumented, and randomized to receive either a thoracic injury with 5 impacts to the chest or no injury. All animals underwent controlled hemorrhage of 25% blood volume followed by 45 min of Zone 1 REBOA. Animals were then resuscitated with shed blood, observed during a critical care period, and euthanized after 6 h of total experimental time. RESULTS There were no differences between the groups at baseline. The only difference after 6 h was a lower hemoglobin in the thoracic trauma group (8.4 ± 0.8 versus 9.4 ± 0.6 g/dL, P = 0.04). The average proximal mean arterial pressures were significantly lower in the thoracic trauma group during aortic occlusion [103 (98-108) versus 117 (115-124) mmHg, P = 0.04]. There were no differences between the pulmonary contusion before REBOA and at the end of the experiment in size (402 ± 263 versus 356 ± 291 mL, P = 0.782) or density (- 406 ± 127 versus - 299 ± 175 HFU, P = 0.256). CONCLUSIONS Thoracic trauma blunted the proximal arterial pressure augmentation during REBOA but had minimal impacts on resuscitative outcomes. This initial study indicates that REBOA does not seem to exacerbate pulmonary contusion in swine, but blunt thoracic injuries may attenuate the expected rises in proximal blood pressure during REBOA.
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Affiliation(s)
- Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA.
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA.
| | - Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
| | - Harris W Kashtan
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Andrew M Wishy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Connor Caples
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Marguerite Spruce
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - John K Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
| | - Lucas P Neff
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Timothy K Williams
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Michael A Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA
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Kashtan HW, Simon MA, Beyer CA, Wishy A, Hoareau GL, Grayson JK, Johnson MA. Effects of Extended Lower Extremity Cooling Following Zone 3 REBOA in a Porcine Hemorrhage Model. Mil Med 2020; 185:42-49. [PMID: 32074339 DOI: 10.1093/milmed/usz306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 08/02/2019] [Accepted: 08/06/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION External cooling of ischemic limbs has been shown to have a significant protective benefit for durations up to 4 hours. MATERIALS AND METHODS It was hypothesized that this benefit could be extended to 8 hours. Six swine were anesthetized and instrumented, then underwent a 25% total blood volume hemorrhage. Animals were randomized to hypothermia or normothermia followed by 8 hours of Zone 3 resuscitative endovascular balloon occlusion of the aorta, then resuscitation with shed blood, warming, and 3 hours of critical care. Physiologic parameters were continuously recorded, and laboratory specimens were obtained at regular intervals. RESULTS There were no significant differences between groups at baseline. There were no significant differences between creatine kinase in the hypothermia group when compared to the normothermia group (median [IQR] = 15,206 U/mL [12,476-19,987] vs 23,027 U/mL [18,745-26,843]); P = 0.13) at the end of the study. Similarly, serum myoglobin was also not significantly different in the hypothermia group after 8 hours (7,345 ng/mL [5,082-10,732] vs 5,126 ng/mL [4,720-5,298]; P = 0.28). No histologic differences were observed in hind limb skeletal muscle. CONCLUSION While external cooling during prolonged Zone 3 resuscitative endovascular balloon occlusion of the aorta appears to decrease ischemic muscle injury, this benefit appears to be time dependent. As the ischemic time approaches 8 hours, the benefit from hypothermia decreases.
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Affiliation(s)
- Harris W Kashtan
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2221 Stockton Blvd, Sacramento, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - Meryl A Simon
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2221 Stockton Blvd, Sacramento, CA.,Heart, Lung, and Vascular Center, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2221 Stockton Blvd, Sacramento, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - Andrew Wishy
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2221 Stockton Blvd, Sacramento, CA.,Heart, Lung, and Vascular Center, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA.,Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
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Youngquist ST, Tonna JE, Bartos JA, Johnson MA, Hoareau GL, Hutin A, Lamhaut L. Current Work in Extracorporeal Cardiopulmonary Resuscitation. Crit Care Clin 2020; 36:723-735. [DOI: 10.1016/j.ccc.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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21
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Nowadly CD, Johnson MA, Hoareau GL, Manning JE, Daley JI. The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for non-traumatic cardiac arrest: A review. J Am Coll Emerg Physicians Open 2020; 1:737-743. [PMID: 33145513 PMCID: PMC7593442 DOI: 10.1002/emp2.12241] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 12/21/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been proposed as a novel approach to managing non-traumatic cardiac arrest (NTCA). During cardiac arrest, cardiac output ceases and perfusion of vital organs is compromised. Traditional advanced cardiac life support (ACLS) measures and cardiopulmonary resuscitation are often unable to achieve return of spontaneous circulation (ROSC). During insertion of REBOA a balloon-tipped catheter is placed into the femoral artery and advanced in a retrograde manner into the aorta while the patient is undergoing cardiopulmonary resuscitation (CPR). The balloon is then inflated to fully occlude the aorta. The literature surrounding the use of aortic occlusion in non-traumatic cardiac arrest is limited to animal studies, case reports and one recent non-controlled feasibility trial. In both human and animal studies, preliminary data show that REBOA may improve coronary and cerebral perfusion pressures and key physiologic parameters during cardiac arrest resuscitation, and animal data have demonstrated improved rates of ROSC. Multiple questions remain before REBOA can be considered as an adjunct to ACLS. If demonstrated to be effective clinically, REBOA represents a potentially cost-effective and generalizable intervention that may improve quality of life for patients with non-traumatic cardiac arrest.
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Affiliation(s)
- Craig D. Nowadly
- Department of Emergency MedicineDavid Grant United States Air Force Medical CenterTravis Air Force BaseSacramentoCaliforniaUSA
- Department of Emergency MedicineUniversity of California at DavisSacramentoCaliforniaUSA
| | - M. Austin Johnson
- Division of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Guillaume L. Hoareau
- Division of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - James E Manning
- Department of Emergency MedicineUniversity of North Carolina School of MedicineChapel HillUSA
| | - James I. Daley
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
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22
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Hoareau GL, Barthélemy A, Goy-Thollot I, Pouzot-Nevoret C, Beyer CA, Walker LE, Stewart IJ, Grayson JK. Reference Intervals for and the Effects of Sample Handling and Sex on Rotational Thromboelastometry in Healthy Adult Pigs. J Am Assoc Lab Anim Sci 2020; 59:322-327. [PMID: 32204749 DOI: 10.30802/aalas-jaalas-19-000095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accurate assessment of coagulation in porcine studies is essential. We sought to establish normal values for porcine rotational thromboelastometry (ROTEM) according to the American Society for Veterinary Clinical Pathology guidelines and to assess the effects of various preanalytical parameters on those measurements. Healthy Yorkshire-cross pigs (n = 81; 46 males and 35 females) were anesthetized. By using a 18-gauge needle attached to a vacuum phlebotomy tube, blood was acquired from the cranial vena cava. Tubes were filled in the following order: evacuation clot tube, EDTA tube, heparin tube, and 2 citrate tubes. The citrate tubes were randomly assigned to 30 min with or without constant agitation on a rocker. The following parameters were reported according to the manufacturer's recommendations: clotting time, clot formation time, α, (tangent to the clot formation curve when the clot firmness is 20 mm), clot firmness after 10 and 20 min, maximal clot firmness, maximum lysis, and lysis indexes at 30 and 45 min. Reference intervals were reported as mean ± 2 SD (parametric distribution) or 2.5th and 97.5th percentile of the population's results (nonparametric distribution). The effects of sex, sampling order, and agitation on ROTEM results were analyzed through linear regression. Neither sex nor sample agitation influenced any of the ROTEM parameters. Combined reference intervals were established for each ROTEM parameter by pooling data from the nonagitated tubes for both male and female pigs. This study is the first to establish ROTEM reference intervals from a large number of male and female adult Yorkshire-cross pigs and to provide a detailed description of preanalytical sample processing.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, California; Department of Surgery, University of Utah, Salt Lake City, Utah;,
| | | | | | | | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, California; Department of Surgery, University of California-Davis Medical Center, Sacramento, California
| | - Lauren E Walker
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, California
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, California; Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, California
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Hoareau GL, Beyer CA, Walker LE, Chung KK, Stewart IJ. Renal Replacement Therapy Capability for the Treatment of Combat-Associated Acute Kidney Injury: A Historical Perspective to Plan for Future Conflicts. Mil Med 2020; 184:81-83. [PMID: 30215751 DOI: 10.1093/milmed/usy221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/03/2018] [Accepted: 08/08/2018] [Indexed: 11/12/2022] Open
Abstract
Trauma-induced acute kidney injury (AKI) has affected many U.S. warfighters throughout history. We seek to provide a historical review of the epidemiology of combat-acquired AKI and to highlight the importance of adapting current renal replacement therapy (RRT) capabilities to prepare for the next armed conflict. While severe AKI was rare in the recent conflicts in Iraq and Afghanistan, an analysis of prior wars suggests that it will be more common in future combat operations characterized by prolonged evacuation times, limited resuscitation capabilities, and delayed aeromedical evacuation. Therefore, the military community must develop RRT capabilities to satisfy the demands of prolonged field care and austere environments. We propose a series of solutions such as re-enforcing forward deployment of conventional RRT capabilities as well as novel therapies such as improvised dialysis systems or sorbent-based RRT.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
| | - Lauren E Walker
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA
| | - Kevin K Chung
- Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Cir, Travis Air Force Base, CA.,Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD
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24
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Hoareau GL, Williams TK, Davidson AJ, Russo RM, Ferencz SAE, Neff LP, Grayson JK, Stewart IJ, Johnson MA. Endocrine Effects of Simulated Complete and Partial Aortic Occlusion in a Swine Model of Hemorrhagic Shock. Mil Med 2020; 184:e298-e302. [PMID: 30371879 DOI: 10.1093/milmed/usy287] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/24/2018] [Accepted: 10/06/2018] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Low distal aortic flow via partial aortic occlusion (AO) may mitigate ischemia induced by resuscitative endovascular balloon occlusion of the aorta (REBOA). We compared endocrine effects of a novel simulated partial AO strategy, endovascular variable aortic control (EVAC), with simulated REBOA in a swine model. MATERIALS AND METHODS Aortic flow in 20 swine was routed from the supraceliac aorta through an automated extracorporeal circuit. Following liver injury-induced hemorrhagic shock, animals were randomized to control (unregulated distal flow), simulated REBOA (no flow, complete AO), or simulated EVAC (distal flow of 100-300 mL/min after 20 minutes of complete AO). After 90 minutes, damage control surgery, resuscitation, and full flow restoration ensued. Critical care was continued for 4.5 hours or until death. RESULTS Serum angiotensin II concentration was higher in the simulated EVAC (4,769 ± 624 pg/mL) than the simulated REBOA group (2649 ± 429) (p = 0.01) at 180 minutes. There was no detectable difference in serum renin [simulated REBOA: 231.3 (227.9-261.4) pg/mL; simulated EVAC: 294.1 (231.2-390.7) pg/mL; p = 0.27], aldosterone [simulated EVAC: 629 (454-1098), simulated REBOA: 777 (575-1079) pg/mL, p = 0.53], or cortisol (simulated EVAC: 141 ± 12, simulated REBOA: 127 ± 9 ng/mL, p = 0.34) concentrations between groups. CONCLUSIONS Simulated EVAC was associated with higher serum angiotensin II, which may have contributed to previously reported cardiovascular benefits. Future studies should evaluate the renal effects of EVAC and the concomitant therapeutic use of angiotensin II.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA
| | - Timothy K Williams
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, 1 Medical Center Blvd, Winston-Salem, NC
| | - Anders J Davidson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
| | - Rachel M Russo
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
| | | | - Lucas P Neff
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
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Hoareau GL, Tibbits EM, Simon MA, Davidson AJ, DeSoucy ES, Faulconer ER, Grayson JK, Stewart IJ, Neff LP, Williams TK, Johnson MA. Renal effects of three endoaortic occlusion strategies in a swine model of hemorrhagic shock. Injury 2019; 50:1908-1914. [PMID: 31466700 DOI: 10.1016/j.injury.2019.08.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/21/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma patients are predisposed to kidney injury. We hypothesized that in shock, zone 3 REBOA would increase renal blood flow (RBF) compared to control and that a period of zone 3 occlusion following zone 1 occlusion would improve renal function compared to zone 1 occlusion alone. MATERIALS AND METHODS Twenty-four anesthetized swine underwent hemorrhagic shock, 45 min of zone 1 REBOA (Z1, supraceliac), zone 3 REBOA (Z3, infrarenal), or no intervention (control) followed by resuscitation with shed blood and 5 h of critical care. In a fourth group (Z1Z3), animals underwent 55 min of zone 3 REBOA following zone 1 occlusion. Physiologic parameters were recorded, blood and urine were collected at specified intervals. RESULTS During critical care, there were no differences in RBF between the Z1 and Z3 groups. The average RBF during critical care in Z1Z3 was significantly lower than in Z3 alone (98.2 ± 23.9 and 191.9 ± 23.7 mL/min; p = 0.046) and not different than Z1. There was no difference in urinary neutrophil gelatinase-associated lipocalin-to-urinary creatinine ratio between Z1 and Z1Z3. Animals in the Z1Z3 group had a significant increase in the ratio at the end of the experiment compared to baseline [median (IQR)] [9.2 (8.2-13.2) versus 264.5 (73.6-1174.6)]. Following Z1 balloon deflation, RBF required 45 min to return to baseline. CONCLUSION Neither zone 3 REBOA alone nor zone 3 REBOA following zone 1 REBOA improved renal blood flow or function. Following zone 1 occlusion, RBF is restored to baseline levels after approximately 45 min.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States.
| | - Emily M Tibbits
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States; Department of General Surgery, David Grant USAF Medical Center, Travis Air Force Base, CA, United States
| | - Meryl A Simon
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States; Heart, Lung, and Vascular Center, David Grant USAF Medical Center, Travis Air Force Base, CA, United States
| | - Anders J Davidson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States; Department of General Surgery, David Grant USAF Medical Center, Travis Air Force Base, CA, United States
| | - Erik S DeSoucy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States; Department of General Surgery, David Grant USAF Medical Center, Travis Air Force Base, CA, United States
| | - E Robert Faulconer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Lucas P Neff
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Timothy K Williams
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, CA, United States; Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States
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Nectoux A, Guidetti M, Barthélemy A, Pouzot-Nevoret C, Hoareau GL, Goy-Thollot I. Assessment of risks of feline mismatched transfusion and neonatal isoerythrolysis in the Lyon (France) area. JFMS Open Rep 2019; 5:2055116919863175. [PMID: 31384478 PMCID: PMC6651689 DOI: 10.1177/2055116919863175] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives The aims of this study were to update the prevalence of different feline blood types in the Lyon (France) area, as well as to determine the risk of mismatched transfusion (MT) and neonatal isoerythrolysis (NI) in kittens with parents of unknown blood type. Methods Blood samples were obtained from blood donor cats and cats admitted to an intensive care unit in Lyon. AB blood typing was performed using an immunochromatographic strip. The risk of MT was estimated by adding the risk of a major transfusion reaction and the risk of a minor transfusion reaction. The risk of NI was estimated according the equation (p²)(q²) + 2pq(q²), with q being the b allele frequency and p = 1 - q. The results were analysed by absolute and relative frequency analysis and multivariate analysis. Results The cohort study population included 320 non-pedigree cats and 37 pedigree cats. The prevalence of blood types A, B and AB was 84.3%, 14.0% and 1.7%, respectively. Considering non-pedigree cats, the prevalence of types A, B and AB was 83.7%, 14.4% and 1.9%, respectively. There were no significant differences of blood type distribution by sex (P = 0.73) or by breed (P = 0.90). Based on these percentages, the risks of MT and NI in non-pedigree cats were 24.3% and 12.3%, respectively. Conclusions and relevance The prevalence of type B cats is high in the Lyon area and associated with high risks of MT and NI. These results confirm the importance of performing blood typing prior to any blood transfusion or mating.
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Affiliation(s)
- Alexandra Nectoux
- Intensive Care Unit (SIAMU), University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | | | - Anthony Barthélemy
- Intensive Care Unit (SIAMU), University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Céline Pouzot-Nevoret
- Intensive Care Unit (SIAMU), University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis AFB, CA, USA
| | - Isabelle Goy-Thollot
- Intensive Care Unit (SIAMU), University of Lyon, VetAgro Sup, Marcy l'Etoile, France
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Hoareau GL, Tibbits EM, Beyer CA, Simon MA, DeSoucy ES, Faulconer ER, Neff LP, Grayson JK, Stewart IJ, Williams TK, Johnson MA. Resuscitative Endovascular Balloon Occlusion of the Aorta: Review of the Literature and Applications to Veterinary Emergency and Critical Care. Front Vet Sci 2019; 6:197. [PMID: 31275952 PMCID: PMC6594359 DOI: 10.3389/fvets.2019.00197] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 06/03/2019] [Indexed: 11/13/2022] Open
Abstract
While hemorrhagic shock might be the result of various conditions, hemorrhage control and resuscitation are the corner stone of patient management. Hemorrhage control can prove challenging in both the acute care and surgical settings, especially in the abdomen, where no direct pressure can be applied onto the source of bleeding. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a promising replacement to resuscitative thoracotomy (RT) for the management of non-compressible torso hemorrhage in human trauma patients. By inflating a balloon at specific levels (or zones) of the aorta to interrupt blood flow, hemorrhage below the level of the balloon can be controlled. While REBOA allows for hemorrhage control and augmentation of blood pressure cranial to the balloon, it also exposes caudal tissue beds to ischemia and the whole body to reperfusion injury. We aim to introduce the advantages of REBOA while reviewing known limitations. This review outlines a step-by-step approach to REBOA implementation, and discusses common challenges observed both in human patients and during translational large animal studies. Currently accepted and debated indications for REBOA in humans are discussed. Finally, we review possible applications for veterinary patients and how REBOA has the potential to be translated into clinical veterinary practice.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Emily M Tibbits
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Meryl A Simon
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Erik S DeSoucy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | | | - Lucas P Neff
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, United States
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Williams TK, Tibbits EM, Hoareau GL, Simon MA, Davidson AJ, DeSoucy ES, Faulconer ER, Grayson JK, Neff LP, Johnson MA. Endovascular variable aortic control (EVAC) versus resuscitative endovascular balloon occlusion of the aorta (REBOA) in a swine model of hemorrhage and ischemia reperfusion injury. J Trauma Acute Care Surg 2019; 85:519-526. [PMID: 30142105 DOI: 10.1097/ta.0000000000002008] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is effective at limiting hemorrhage from noncompressible sources and restoring but causes progressive distal ischemia, supraphysiologic pressures, and increased cardiac afterload. Endovascular variable aortic control (EVAC) addresses these limitations, while still controlling hemorrhage. Previous work demonstrated improved outcomes following a 90-minute intervention period in an uncontrolled hemorrhage model. The present study compares automated EVAC to REBOA over an occlusion period reflective of contemporary REBOA usage. METHODS Following instrumentation, 12 Yorkshire-cross swine underwent controlled 25% hemorrhage, a 45-minute intervention period of EVAC or REBOA, and subsequent resuscitation with whole blood and critical care for the remainder of a 6-hour experiment. Hemodynamics were acquired continuously, and laboratory parameters were assessed at routine intervals. Tissue was collected for histopathologic analysis. RESULTS No differences were seen in baseline parameters. During intervention, EVAC resulted in more physiologic proximal pressure augmentation compared with REBOA (101 vs. 129 mm Hg; 95% confidence interval [CI], 105-151 mm Hg; p = 0.04). During critical care, EVAC animals required less than half the amount of crystalloid (3,450 mL; 95% CI, 1,215-5,684 mL] vs. 7,400 mL [95% CI, 6,148-8,642 mL]; p < 0.01) and vasopressors (21.5 ng/kg [95% CI, 7.5-35.5 ng/kg] vs. 50.5 ng/kg [95% CI, 40.5-60.5 ng/kg]; p = 0.05) when compared with REBOA animals. Endovascular variable aortic control resulted in lower peak and final lactate levels. Endovascular variable aortic control animals had less aortic hyperemia from reperfusion with aortic flow rates closer to baseline (36 mL/kg per minute [95% CI, 30-44 mL/kg per minute] vs. 51 mL/kg per minute [95% CI, 41-61 mL/kg per minute]; p = 0.01). CONCLUSIONS For short durations of therapy, EVAC produces superior hemodynamics and less ischemic insult than REBOA in this porcine-controlled hemorrhage model, with improved outcomes during critical care. This study suggests EVAC is a viable strategy for in-hospital management of patients with hemorrhagic shock from noncompressible sources. Survival studies are needed to determine if these early differences persist over time.
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Affiliation(s)
- Timothy K Williams
- From the Department of Vascular and Endovascular Surgery (T.K.W.), Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Clinical Investigation Facility (T.K.W., E.M.T., G.L.H., M.A.S., A.J.D., E.S.D., E.R.F., J.K.G., L.P.N., M.A.J.), David Grant Medical Center, Travis Air Force Base, California; Department of General Surgery (E.M.T., A.J.D., E.S.D.), David Grant Medical Center, Travis Air Force Base, California; Department of Surgery (E.M.T., M.A.S., A.J.D., E.S.D.), University of California Davis Medical Center, Sacramento, California; Heart, Lung, and Vascular Center (M.A.S.), David Grant Medical Center, Travis Air Force Base, California; Department of Surgery (L.P.N.), Emory University Hospital, Atlanta, Georgia; and Department of Emergency Medicine (M.A.J.), University of California Davis Medical Center, Sacramento, California
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DeSoucy ES, Davidson AJ, Hoareau GL, Simon MA, Tibbits EM, Ferencz SAE, Grayson JK, Galante JM. Pharmacokinetics of Tranexamic Acid via Intravenous, Intraosseous, and Intramuscular Routes in a Porcine (Sus scrofa) Hemorrhagic Shock Model. J Spec Oper Med 2019; 19:80-84. [PMID: 31910476 DOI: 10.55460/cogq-2cy1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Intravenous (IV) tranexamic acid (TXA) is an adjunct for resuscitation in hemorrhagic shock; however, IV access in these patients may be difficult or impossible. Intraosseous (IO) or intramuscular (IM) administration could be quickly performed with minimal training. We investigated the pharmacokinetics of TXA via IV, IO, and IM routes in a swine model of controlled hemorrhagic shock. METHODS Fifteen swine were anesthetized and bled of 35% of their blood volume before randomization to a single 1g/10mL dose of IV, IO, or IM TXA. Serial serum samples were obtained after TXA administration. These were analyzed with high-pressure liquid chromatography-mass spectrometry to determine drug concentration at each time point and define the pharmacokinetics of each route. RESULTS There were no significant differences in baseline hemodynamics or blood loss between the groups. Peak concentration (Cmax) was significantly higher in IV and IO routes compared with IM (p = .005); however, the half-life of TXA was similar across all routes (p = .275). CONCLUSION TXA administration via IO and IM routes during hemorrhagic shock achieves serum concentrations necessary for inhibition of fibrinolysis and may be practical alternatives when IV access is not available.
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Tibbits EM, Hoareau GL, Simon MA, Davidson AJ, DeSoucy ES, Faulconer ER, Neff LP, Grayson JK, Johnson MA, Williams TK. Stepwise Reperfusion After Zone 1 REBOA: Is Repositioning to Zone 3 a Useful Maneuver? JEVTM 2018. [DOI: 10.26676/jevtm.v2i3.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives: One limitation of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is hemodynamic instability upon balloon deflation due to distal hyperemia and washout of ischemic metabolites. We sought to determine whether stepwise reperfusion after supraceliac (Zone-1) REBOA by transitioning to infrarenal (Zone-3) occlusion would mitigate the physiologic consequences of balloon deflation and decrease hemodynamic instability.
Methods: Twelve anesthetized swine underwent controlled hemorrhage of 25% blood volume, 45 minutes of Zone-1 REBOA, then resuscitation with shed blood. Standardized critical care began with deflation of the Zone-1 balloon in all animals, and continued for six hours. Half of the animals were randomly assigned to Zone-3 REBOA for an additional 45 minutes following Zone-1 balloon deflation.
Results: There were no differences in physiology at baseline, during the initial 30 minutes of hypotension, or during the 45 minutes of Zone-1 occlusion. After Zone-1 balloon deflation, there was no difference in proximal mean arterial pressure (pMAP) with or without Zone-3 occlusion, or percentage of critical care time spent within the target pMAP range between 65 and 75 mm Hg. There were also no significant differences in peak lactate concentration or resuscitation requirements.
Conclusions: In an animal model of hemorrhagic shock and Zone-1 REBOA, subsequent Zone-3 aortic occlusion did not add significant ischemic burden, but it also did not provide significant hemodynamic support. The effect of this strategy on functional outcomes warrants further study. Continued investigation is necessary to determine optimal resuscitative support strategies during reperfusion following Zone-1 REBOA.
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Hoareau GL, Epstein SE, Palm C, Ybarra W, Jandrey KE, Cowgill LD. Resolution of anuric acute kidney injury in a dog with multiple organ dysfunction syndrome. J Vet Emerg Crit Care (San Antonio) 2014; 24:724-30. [PMID: 25377656 DOI: 10.1111/vec.12248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 09/28/2014] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To describe the management and resolution of anuric acute kidney injury (AKI) in a dog with multiple organ dysfunction syndrome (MODS) associated with gallbladder wall necrosis. CASE SUMMARY An 11-year-old neutered female spayed dog was referred for evaluation of anuria following cholecystectomy. Following surgery, the patient became anuric with no response to appropriate medical therapy. During the course of hospitalization, the patient developed MODS as evidenced by alteration in renal function, but also cardiovascular dysfunction, coagulation disorders, and hypoglycemia. Several hemodialysis treatments were performed and, along with intensive care, led to resolution of clinical signs and return of urine production. NEW OR UNIQUE INFORMATION This report describes resolution of anuria in a dog with AKI and MODS. In this clinical setting, despite a poor prognosis, survival and recovery of adequate renal function were possible with medical management that included hemodialysis.
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Affiliation(s)
- Guillaume L Hoareau
- Veterinary Medical Teaching Hospital (Hoareau, Ybarra); School of Veterinary Medicine, University of California-Davis, Davis, CA, 95616
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Hoareau GL, Jandrey KE, Burges J, Bremer D, Tablin F. Comparison of the platelet-rich plasma and buffy coat protocols for preparation of canine platelet concentrates. Vet Clin Pathol 2014; 43:513-8. [DOI: 10.1111/vcp.12195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Guillaume L. Hoareau
- William R. Pritchard Veterinary Medical Teaching Hospital; University of California-Davis; Davis CA USA
| | - Karl E. Jandrey
- Department of Surgical and Radiological Sciences; University of California-Davis; Davis CA USA
| | - Julie Burges
- Transfusion Medicine Service; William R. Pritchard Veterinary Medical Teaching Hospital; University of California-Davis; Davis CA USA
| | - Daphne Bremer
- Vanderbilt Institute for Global Health; Nashville TN USA
| | - Fern Tablin
- Anatomy, Physiology and Cell Biology; School of Veterinary Medicine; University of California-Davis; Davis CA USA
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Abstract
Background Brachycephalic dogs are at risk for arterial hypertension and obstructive sleep apnea, which are both associated with chronic magnesium (Mg) depletion. Hypothesis/Objectives To compare the period prevalence of hypomagnesemia between Boxers and Bulldogs presented to a referral teaching hospital. To screen a group of Bulldogs for evidence of hypomagnesemia, and to obtain pilot data regarding the utility of parenteral Mg tolerance testing (PMgTT) in the diagnosis of whole‐body Mg deficiency. Animals Chemistry laboratory submissions were retrospectively analyzed for serum total Mg (tMg) in Boxers and Bulldogs. Prospectively, 16 healthy client‐owned Bulldogs were enrolled. Methods Retrospective case study. tMg concentrations were compared between Boxers and Bulldogs. Dogs with low serum albumin or high serum creatinine concentrations were excluded. Prospectively, ionized Mg (iMg), tMg, and arterial blood pressure were measured and iMg‐to‐tMg ratio (iMg : tMg) was calculated. Parenteral Mg tolerance testing (PMgTT) was performed in 3/16 dogs. Results In the retrospective study, period prevalence of hypomagnesemia was 4.7% in Boxers and 15% in Bulldogs (P = .02). The risk ratio for hypomagnesemia in Bulldogs was 1.8 when compared to Boxers (CI: 1.3–2.7). In the prospective study, iMg was [median (interquartile)] 0.43 (0.42–0.46) mmol/L (reference range 0.4–0.52), tMg was 1.9 (1.8–1.9) mg/dL (reference range 1.9–2.5). iMg : tMg was [mean (±SD)] 0.59 ± 0.04. Percentage retention after PMgTT were 55%, 95%, and 67%, respectively. Conclusions and Clinical Importance Mg deficiency is common in Bulldogs and could contribute to comorbidities often observed in this breed. iMg : tMg and PMgTT might prove helpful in detecting chronic subclinical Mg deficiency.
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Affiliation(s)
- M S Mellema
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California - Davis, Davis, CA
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Hoareau GL, Jourdan G, Mellema M, Verwaerde P. Evaluation of arterial blood gases and arterial blood pressures in brachycephalic dogs. J Vet Intern Med 2012; 26:897-904. [PMID: 22574946 DOI: 10.1111/j.1939-1676.2012.00941.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 03/09/2012] [Accepted: 03/27/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Brachycephalic dogs (BD) are prone to congenital upper airway obstruction (brachycephalic syndrome, BS). In humans suffering from sleep apnea, upper airway obstruction is known to cause hypertension. There is no information regarding the influence of BS in dogs on cardiorespiratory physiology. HYPOTHESIS BD are prone to lower P(a) O(2), higher P(a) CO (2), and hypertension compared with meso- or dolicocephalic dogs (MDD). ANIMALS Eleven BD and 11 MDD. METHODS After a questionnaire was completed by the owner, a physical examination was performed. Height and thoracic circumferences were measured. Arterial blood gases, electrolyte concentrations, and packed cell volume (PCV) were measured. Systolic (SAP), mean (MAP), and diastolic (DAP) arterial blood pressure recordings were performed. RESULTS A total of 7 French and 4 English bulldogs met the inclusion criteria. The control group consisted in 6 Beagles, 2 mixed breed dogs, 1 Staffordshire Bull Terrier, 1 Parson Russell Terrier, and 1 Australian Cattle Dog. Statistically, BD had lower P(a) O(2), higher P(a) CO2, and higher PCV when compared with controls (86.2 ± 15.9 versus 100.2 ± 12.6 mmHg, P = .017; 36.3 ± 4.6 versus 32.7 ± 2.6 mmHg, P = .019; 48.2 ± 3.5 versus 44.2 ± 5.4%, P = .026, respectively). Also, they had significantly higher SAP (177.6 ± 25.0 versus 153.5 ± 21.7 mmHg, P = .013), MAP (123.3 ± 17.1 versus 108.3 ± 12.2 mmHg, P = .014), and DAP (95.3 ± 19.2 versus 83.0 ± 11.5 mmHg, P = .042). BD with a P(a) CO (2) >35 mmHg were significantly older than those with a P(a) CO (2) ≤35 mmHg (58 ± 16 and 30 ± 11 months, P = .004). CONCLUSION Results of this study suggest that some BD are prone to lower P(a) O(2), higher P(a) CO (2), and hypertension when compared with MDD. Age may be a contributing factor.
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Affiliation(s)
- G L Hoareau
- School of Veterinary Medicine, William R. Pritchard Veterinary Medical Teaching Hospital.
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Hoareau GL, Mellema MS, Silverstein DC. Indication, management, and outcome of brachycephalic dogs requiring mechanical ventilation. J Vet Emerg Crit Care (San Antonio) 2011; 21:226-35. [PMID: 21631708 DOI: 10.1111/j.1476-4431.2011.00635.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the frequency, and need for mechanical ventilation (MV) in a population of brachycephalic dogs (BD) compared with non-BD. Also, to describe the pre-MV abnormalities, ventilator settings used, the cardiovascular and pulmonary monitoring results and complications encountered in the same BD population. In addition, we sought to identify factors associated with successful weaning and describe outcomes of BD requiring MV. DESIGN Retrospective observational study (1990-2008). SETTING University Small Animal Teaching Hospital. ANIMALS Fifteen BD managed with MV. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Signalment, indication for MV, ventilator settings, arterial blood gas values, duration of MV, complications, and outcome were recorded for each patient enrolled in study. BD were more likely to receive MV than non-BD (P=0.036). Out of the 15 dogs that fulfilled the inclusion criteria 7 (47%) underwent MV for impending respiratory fatigue, 6 (40%) for hypoxemia and 2 for hypercapnea. The most common underlying disease was aspiration pneumonia. Duration of MV ranged from 2 to 240 hours (median 15 hours). Seven patients were weaned (47%). Seven dogs had a temporary tracheostomy tube and 5 of them (71%) were weaned. Dogs that were weaned had a significantly greater preweaning trial PaO₂/FiO₂ ratio than those that were not (359 ± 92 versus 210 ± 57 mm Hg, P=0.025). No significant difference for weaning success between dogs with and those without a tracheostomy was detected (P=0.132). The discharge rate was 27% (all from the respiratory fatigue group). CONCLUSION Among all dogs admitted to ICU, BD were more likely to receive MV than non-BD. Aspiration pneumonia was frequently identified as the underlying cause of respiratory compromise. The survival rate for BD undergoing MV was not markedly different from previous studies. Weaning of BD from MV may be facilitated by employing preemptive strategies such as performing tracheostomy tube placements.
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Affiliation(s)
- Guillaume L Hoareau
- Section of Critical Care, Department of Clinical Studies - Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104-6010, USA.
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