Hemorrhage-induced alpha-adrenergic signaling results in myocardial TNF-alpha expression and contractile dysfunction

Hemorrhagic shock (HS), secondary to major blood loss, frequently precedes multiple organ dysfunction and is accompanied by a surge in circulating catecholamine levels. Expression of the cardiodepressant cytokine, tumor necrosis factor-alpha (TNF-alpha), has been observed in the heart after HS and resuscitation (HS/R) and alpha(1)-adrenergic blockade prevented translocation of the nuclear transcription factor, NF-kappa B, to the nucleus. We hypothesized that alpha(1)-adrenergic stimulation induces myocardial TNF-alpha expression, which results in depressed cardiac function after HS/R. The role of alpha(1)-adrenergic stimulation in myocardial TNF-alpha expression and depressed cardiac function after HS/R was assessed by treatment with the alpha(1)-adrenergic inhibitor, prazosin hydrochloride (1 mg/kg ip), for 1 h before the onset of hemorrhage. In addition, TNF-alpha was neutralized with a specific antibody (600 microl/kg iv) 5 min before hemorrhage. HS was induced by the withdrawal of blood to a mean blood pressure of 50 mmHg for 1 h. Contractile function was measured with the use of a Langendorff apparatus 2 h after the end of HS. HS/R led to significant decreases in left ventricular developed tension and in the maximal rate of pressure increase over time during both contraction and relaxation. Myocardial expression of TNF-alpha measured by enzyme-linked immunosorbent assay increased significantly after 30 min of hemorrhage and peaked after 60 min of HS and 45 min of resuscitation. Depression in cardiac function after HS/R was reversed by 85% in hearts from rats treated with a TNF-alpha neutralizing antibody and by 90% in hearts from rats treated with prazosin hydrochloride. We conclude that HS activates a alpha(1)-adrenergic pathway, resulting in TNF-alpha expression in the heart and depressed myocardial contractile function.

Accuracy and precision of the portable StatPal II and the laboratory-based NOVA stat profile 1 for measurement of pH, P(CO2), and P(O2) in equine blood

OBJECTIVE

To investigate the accuracy and precision of the portable, battery-powered StatPal II and the laboratory-based NOVA StatProfile 1 blood gas and pH analyzers for use in analysis of equine blood.

STUDY DESIGN

Patient sample comparison and whole blood tonometry.

SAMPLE POPULATION

Patient sample comparison: 125 arterial or venous blood samples from 49 healthy, awake, or anesthetized horses or ponies. Tonometry: venous blood samples from 11 healthy Thoroughbred horses.

MATERIALS AND METHODS

Arterial and venous blood taken from awake and anesthetized equine patients was placed in an ice-water bath, then analyzed within 30 minutes of collection. Bias and limits of agreement between analyzers in measurement of pH, P(CO2), and P(O2) were calculated according to the method of Bland and Altman. Tonometry, using analyzed gases with a range of P(O2) of 28 to 286 mm Hg and P(CO2) of 21 to 85 mm Hg, was performed on equine whole blood or blood with abnormally high (55%) or low (20%) hematocrit. Samples were introduced directly from the tonometer into the analyzers. Inaccuracy (% of target value) and imprecision (coefficient of variation) were determined for each instrument. In addition, results of analysis of blood samples introduced into the analyzers at 36 degrees C, 0 to 3 degrees C, and 22 degrees C were compared.

RESULTS

In the patient sample comparisons, bias between analyzers (StatPal-NOVA) for measurement of P(O2) less than 60 mm Hg was -0.33+/-6.2 mm Hg (x +/-2 SD) and for P(O2) between 60 and 110 mm Hg bias was -1.48+/-9.2 mm Hg. Bias was 46.5+/-67 mm Hg (significantly different from bias at the lower P(O2) levels) for measurement of P(O2) values of 111 to 505 mm Hg, and at P(O2) values greater than 110 mm Hg, bias increased with increasing P(O2). During the course of the study, a significant shift in bias between instruments occurred for P(CO2) and pH measurement, coincident with a change of P(CO2) and pH electrodes in the NOVA and use of a new lot of StatPal sensors. Bias (StatPal-NOVA) for P(CO2) before and after the electrode change was -3.74+/-4.2 and -0.88+/-6.8 mm Hg, and bias for pH before and after the electrode change was 0.026+/-0.034 and -0.024+/-0.038. The change in bias was significant (P<.05). In the whole blood tonometry trials, mean recovered values of P(CO2) and P(O2) from blood with a normal hematocrit ranged from 94% to 109% of target values for StatPal and from 98% to 107% for NOVA. Imprecision ranged from 3.3% to 5.3% for StatPal and from 2.2% to 4.3% for NOVA. With extremes of hematocrit (55% and 20%), StatPal's mean recovered P(CO2) values were 115% and 112% of the target value of 21 mm Hg, whereas NOVA's recovered P(CO2) values were similar to those recovered from samples with normal hematocrit. Introduction of cold blood samples (0 to 3 degrees C) into StatPal resulted in P(CO2) readings that were approximately 2 mm Hg lower than those of 22 degrees C and 36 degrees C samples (P<.05). No other effects of sample temperature were found for either instrument.

CONCLUSIONS

StatPal and NOVA are of similar accuracy and demonstrate acceptable precision for measurement of P(CO2) and P(O2) in equine blood with values in the normal arterial and venous range. Mean recovered values during tonometry differed by as much as 10% between instruments, indicating that they should not be used interchangeably for a single patient or for a group of subjects in a research setting.

CLINICAL RELEVANCE

The StatPal is a portable blood gas analyzer of acceptable accuracy and precision, for clinical or investigational work in horses.

Effect of ligation on internal carotid artery blood pressure in horses

The effect of a single ligature on back pressure in the internal carotid artery was studied in nine horses. In six anesthetized horses, one internal carotid artery was catheterized 2 cm from its origin and blood pressure was recorded continuously. Then the artery was ligated, pressure was recorded again, and the horses were euthanatized. In another three anesthetized horses, indwelling catheters were placed in both internal carotid arteries and a loose ligature was placed proximal to one catheter. After horses recovered from anesthesia, the ligature was tied and blood pressure was recorded in both arteries on that day and 3 days later, then these horses were euthanatized. The anatomy of the cerebral arteries was examined in all nine horses. Blood pressure in the internal carotid arteries did not change after ligation. Subjectively, collateral channels considered most likely to maintain blood pressure in the ligated internal carotid artery were the caudal intercarotid artery and the cerebral arterial circle. We concluded that ligation of the internal carotid artery would not prevent severe hemorrhage from the internal carotid artery in horses with guttural pouch mycosis until the ligated artery thrombosed to the level of the lesion.

Closed-circuit liquid injection isoflurane anesthesia in the horse

Six horses were administered isoflurane anesthesia by liquid injection into a closed breathing circuit according to the square root of time model. The unit dose (UD) was calculated using Lowe's formula to provide an end-tidal concentration of 1.3%, or the minimum alveolar concentration of isoflurane. The mean UD was 4.2 +/- 0.2 mL. The mean end-tidal isoflurane concentration (ETiso) for each interval after injection, and the peak and minimum concentrations for each injection interval, did not change beginning with the second injection, indicating that the square root of time model accurately predicted isoflurane uptake in the horse. Mean ETiso measured for the interval after the first injection was 0.68 +/- 0.06%, which was significantly (p < .05) lower than the mean concentration after all subsequent injections (1.1 +/- 0.1%). Mean peak end-tidal concentration was 1.1 +/- 0.25% after the first injection and 1.7 +/- 0.26% for all other injections. Mean minimum end-tidal concentration was 0.77 +/- 0.13% for all injection periods. This model proved to be an acceptable technique for administration of isoflurane anesthesia to horses.

An unusual cause of increasing airway pressure during anesthesia

A mare with a thoracic laceration was anesthetized with halothane-O2 for surgical repair. Shortly after initiation of controlled ventilation, inspiratory plateau pressure began to increase. The increase in pressure continued despite decreasing the tidal volume. Tension pneumothorax was suspected, but because arterial PCO2 and PO2 were normal, the anesthetic apparatus was examined. Excess gas continued to exit through the bellows pop-off valve even when the fresh gas flow was turned off. It was determined that driving gas from the ventilator was entering the breathing circuit through a hole in the bellows. Testing the integrity of the bellows before use is suggested to avoid this potentially harmful complication.

Comparison of carbonated lidocaine and lidocaine hydrochloride for caudal epidural anesthesia in horses

A double-blind comparison of carbonated lidocaine and lidocaine hydrochloride in caudal epidural anesthesia was performed in 8 horses. Among 5 horses with successfully paired bilateral caudal epidural blockades, no significant differences in onset time, duration, or sensory blockade were demonstrated. In the present study, carbonated lidocaine did not offer an advantage over the hydrochloride salt for caudal epidural anesthesia in the horse.

Malignant hyperthermia in a halothane-anesthetized horse

Malignant hyperthermia developed in a 4-year-old Thoroughbred horse following 3 hours and 15 minutes of halothane anesthesia, with supplementary succinylcholine. Clinical signs included fever, sweating, hyperventilation, tachycardia, and decreased blood pressure followed by a rapid increase in blood pressure. Biochemical aberrations included hypocalcemia, hyperkalemia, hyperphosphatemia, myoglobinuria, and high creatine phosphokinase and ornithine carbamyl transferase activities. Treatment consisted initially of surface cooling with cold water, alcohol and ice, IV administration of cooled balanced electrolyte solutions and sodium bicarbonate, and removal from the anesthetic and rebreathing circuit. Oxygen was given by endotracheal insufflation. The rectum was then packed with ice, the horse was moved to a recovery raft and pool, and his body was packed in ice. Xylazine and dantrolene were given during recovery from anesthesia. Following recovery, treatment consisted of administration of balanced electrolyte solutions, calcium borogluconate, potassium penicillin, meperidine, and additional dantrolene. Muscle biopsy demonstrated exaggerated contracture responses to halothane and caffeine, confirming a diagnosis of malignant hyperthermia. The horse was returned to training following a routine postsurgical convalescent period.