Shen-fu injection alleviates acute renal injury by reducing cytokine levels and modulating apoptosis in a porcine hemorrhagic shock model

ABSTRACT Purpose Shen-fu injection (SFI) was used to intervene in the resuscitation of porcine hemorrhagic shock (HS) model to study its protective effects on acute kidney injury. Methods After 60 min of HS, 28 animals were randomly assigned into four groups. The groups were as follows: hemorrhagic shock group (HS); HS resuscitation with shed-blood group (HSR); HS resuscitation with shed-blood and SFI (1 mL·kg-1) group (HSR-SFI); and the sham operation group (Sham). The bloods were analyzed for serum creatinine (sCr), cystatin C (CysC) and neutrophil gelatinase-associated lipocalin (NGAL). BAX, Bcl-2, and caspase-3 protein expressions by Western blot analysis and immunohistochemical staining. The renal tissues were removed and pathologic changes were observed. Results Mean aortic pressure (MAP) in HSR-SFI groups were higher than that in HSR groups after shock. At the 6th hour after shock, the urine volume per hour in the HSR-SFI groups was more than that in the HSR groups. The sCr, NGAL, CysC and cytokine levels of HSR-SFI groups were lower. The Bcl-2 expression was increased in the HSR-SFI groups. The BAX and caspase-3 expressions were reduced. The histopathologic score in the HSR-SFI was lower. Conclusions SFI may reduce the risk of acute kidney injury (AKI) following hemorrhagic shock by attenuating systemic inflammatory responses, and regulating the expression of apoptosis-related proteins.

Dexmedetomidine preconditioning protects against lung injury in hemorrhagic shock rats / Pré-condicionamento com dexmedetomidina protege contra lesão pulmonar em ratos com choque hemorrágico

Abstract Background and objectives: Dexmedetomidine has demonstrated protective effects against lung injury in vitro. Here, we investigated whether dexmedetomidine preconditioning protected against lung injury in hemorrhagic shock rats. Methods: Male Sprague-Dawley rats were randomly divided into four groups (n = 8): control group, hemorrhagic shock group, 5 ug.kg-1 dexmedetomidine (DEX1) group, and 10 ug.kg-1 dexmedetomidine (DEX2) group. Saline or dexmedetomidine were administered over 20 min. 30 min after injection, hemorrhage was initiated in the hemorrhagic shock, DEX1 and DEX2 group. Four hours after resuscitation, protein and cellular content in bronchoalveolar lavage fluid, and the lung histopathology were measured. The malondialdehyde, superoxide dismutase, Bcl-2, Bax and caspase-3 were also tested in the lung tissue. Results: Compare with hemorrhagic shock group, 5 ug.kg-1 dexmedetomidine pretreatment reduced the apoptosis (2.25 ± 0.24 vs. 4.12 ± 0.42%, p < 0.05), histological score (1.06 ± 0.12 vs. 1.68 ± 0.15, p < 0.05) and protein (1.92 ± 0.38 vs. 3.95 ± 0.42 mg.mL-1, p < 0.05) and WBC (0.42 ± 0.11 vs. 0.92 ± 0.13 × 109/L, p < 0.05) in bronchoalveolar lavage fluid. Which is correlated with increased superoxide dismutase activity (8.35 ± 0.68 vs. 4.73 ± 0.44 U.mg-1 protein, p < 0.05) and decreased malondialdehyde (2.18 ± 0.19 vs. 3.28 ± 0.27 nmoL.mg-1 protein, p < 0.05). Dexmedetomidine preconditioning also increased the Bcl-2 level (0.55 ± 0.04 vs. 0.34 ± 0.05, p < 0.05) and decreased the level of Bax (0.46 ± 0.03 vs. 0.68 ± 0.04, p < 0.05), caspase-3 (0.49 ± 0.03 vs. 0.69 ± 0.04, p < 0.05). However, we did not observe any difference between the DEX1 and DEX2 groups for these (p > 0.05). Conclusion: Dexmedetomidine preconditioning has a protective effect against lung injury caused by hemorrhagic shock in rats. The potential mechanisms involved are the inhibition of cell death and improvement of antioxidation. But did not show a dose-dependent effect.

Resumo Justificativa e objetivos: Dexmedetomidina demonstrou efeitos protetores contra a lesão pulmonar in vitro. Neste estudo, investigamos se o pré-condicionamento com dexmedetomidina protege contra a lesão pulmonar em ratos com choque hemorrágico. Métodos: Ratos machos, Sprague-Dawley, foram aleatoriamente divididos em quatro grupos (n = 8): grupo controle, grupo com choque hemorrágico, grupo com 5 µg.kg-1 de dexmedetomidina (DEX1) e grupo com 10 µg.kg-1 de dexmedetomidina (DEX2). Solução salina ou dexmedetomidina foi administrada durante 20 minutos. Trinta minutos após a injeção, a hemorragia foi iniciada nos grupos choque hemorrágico, DEX1 e DEX2. Quatro horas após a ressuscitação, a proteína e o conteúdo celular no lavado broncoalveolar e a histopatologia pulmonar foram medidos. Malondialdeído, superóxido dismutase, Bcl-2, Bax e caspase-3 também foram testados no tecido pulmonar. Resultados: Na comparação com o grupo choque hemorrágico, o pré-tratamento com 5 ug.kg-1 de dexmedetomidina reduziu a apoptose (2,25 ± 0,24 vs. 4,12 ± 0,42%, p < 0,05), escore histológico (1,06 ± 0,12 vs. 1,68 ± 0,15, p < 0,05) e proteína (1,92 ± 0,38 vs. 3,95 ± 0,42 mg.mL-1, p < 0,05) e leucócitos (0,42 ± 0,11 vs. 0,92 ± 0,13 × 109/L, p < 0,05) no lavado broncoalveolar; o que está correlacionado com o aumento da atividade da superóxido dismutase (8,35 ± 0,68 vs. 4,73 ± 0,44 U.mg-1 de proteína, p < 0,05) e diminuição do malondialdeído (2,18 ± 0,19 vs. 3,28 ± 0,27 nmoL.mg-1 de proteína, p < 0,05). O pré-condicionamento com dexmedetomidina também aumentou o nível de Bcl-2 (0,55 ± 0,04 vs. 0,34 ± 0,05, p < 0,05) e diminuiu o nível de Bax (0,46 ± 0,03 vs. 0,68 ± 0,04, p < 0,05), caspase-3 (0,49 ± 0,03 vs. 0,69 ± 0,04, p < 0,05). No entanto, não houve diferença entre os grupos DEX1 e DEX2 para essas proteínas (p > 0,05). Conclusão: O pré-condicionamento com dexmedetomidina tem um efeito protetor contra a lesão pulmonar causada por choque hemorrágico em ratos. Os potenciais mecanismos envolvidos são a inibição da morte celular e a melhora da antioxidação. Porém, não mostrou um efeito dose-dependente.

Effects of cococonut water and simvastatin in the treatment of sepsis and hemorrhagic shock in rats

ABSTRACT PURPOSE: To evaluate the effects of modified coconut water as fluid of resuscitation combined with simvastatin in hemorrhagic shock and sepsis model in rats. METHODS: Four groups of Wistar rats with hemorrhagic shock and abdominal sepsis were studied (n=8/group). Rats were bled and maintained at a mean blood pressure 35mmHg for 60min. They were then resuscitated with: 1) saline 0.9%; 2) coconut water+3% NaCl; 3) coconut water+NaCl 3%+simvastatin microemulsion (10 mg/kg i.v.; 4) normal coconut water. At 8h post-resuscitation, blood and lungs were collected for exams. RESULTS: Clinical scores, TNF-α, IL-1β, liver/kidney proof levels, and lung injury were significantly reduced in coconut water+NaCl 3%+simvastatin group treated rats, comparing with the other resuscitation treatments. CONCLUSIONS: Resuscitation with coconut water with Nacl 3%+simvastatin had a significant beneficial effect on downregulating cytokines and decreasing lung injury in a rat model of abdominal sepsis and hemorrhagic shock. We also demonstrated that coconut water with Nacl 3%+simvastatin administration clearly made liver and kidney function better and improved clinical score.

Effect of N-acetylcysteine in hearts of rats submitted to controlled hemorrhagic shock / Efeito da N-acetilcisteína em corações de ratos submetidos ao choque hemorrágico controlado

Abstract Introduction: Pharmacological therapy is a strategy for the prevention of complications associated with ischemia and reperfusion injury that occurs after volume replacement in the treatment of hemorrhagic shock. Objective: The aim of this study was to evaluate the effect of N-acetylcysteine associated with fluid resuscitation in cardiac injury in a rat hemorrhagic shock model. Methods: Mice Wister male rats were randomly and subjected to controlled hemorrhagic shock for 60 min. and then, subjected to resuscitation with Ringer lactate. In a group of six animals, 150mg/kg of N-acetylcysteine were added to fluid volume replacement. The animals were observed for 120 min and after this period, were euthanized and cardiac tissue was collected for histopathological analysis and measurement of thiobarbituric acid reactive substances and pro-and anti-inflammatory interleukin. Results: Cardiac tissue of the group treated with N-acetylcysteine showed lower concentrations of thiobarbituric acid reactive substances (0.20±0.05 vs. 0.27±0.05, P=0.014) and reduced histopathological damage and edema when compared to the group whose volume replacement occurred only with Ringer lactate. There was no difference in the expression of cytokines interleukin 6 (2,138.29±316.89 vs. 1,870.16±303.68, P=0.091) and interleukin 10 (1.019,83±262,50 vs. 848.60±106.5, P=0.169) between the treated groups. Conclusion: The association of N-acetylcysteine on volume replacement attenuates oxidative stress in the heart, as well myocardial damage and edema, but does not modify the expression of inflammatory cytokines. .

Resumo Introdução: A terapia farmacológica é uma estratégia de prevenção das complicações associadas à lesão de isquemia e reperfusão tecidual que ocorre após a reposição volêmica no tratamento do choque hemorrágico. Objetivo: O objetivo deste estudo foi avaliar a repercussão da N-acetilcisteína associada à reposição volêmica na lesão cardíaca em modelo de choque hemorrágico em ratos. Métodos: Ratos Wistar, machos, foram randomizados e submetidos ao choque hemorrágico controlado por 60 minutos e, depois, submetidos à reposição volêmica com Ringer Lactato. Em um grupo de seis animais, foram adicionados 150 mg/Kg de N-acetilcisteína ao fluido de reposição volêmica. Os animais foram observados por 120 minutos e após este período foram submetidos à eutanásia e coleta do tecido cardíaco para análise histopatológica e dosagem de substâncias reativas ao ácido tiobarbitúrico e interleucinas pró e anti-inflamatórias. Resultados: Foi observada menor concentração de substâncias reativas ao ácido tiobarbitúrico (0,20±0,05 vs. 0,27±0,05, P=0,014) e menor dano histopatológico e edema no tecido cardíaco do grupo tratado com N-acetilcisteína em relação ao grupo cuja reposição volêmica ocorreu somente com Ringer Lactato. Não foi observada diferença da expressão das citocinas interleucina 6 (2.138,29±316,89 vs. 1.870,16±303,68, P=0,091) e interleucina 10 (1.019,83±262,50 vs. 848,60±106,5, P=0,169) entre os grupos tratados. Conclusão: A associação da N-acetilcisteína na reposição volêmica atenua o estresse oxidativo no coração, assim como dano e edema miocárdicos, porém, não modifica a expressão de citocinas inflamatórias. .

Effect of N-acetylcysteine on pulmonary cell death in a controlled hemorrhagic shock model in rats / Efeito da N-acetilcisteína na morte celular pulmonar em um modelo de choque hemorrágico controlado em ratos

PURPOSE: To evaluate the effect of N-acetylcysteine (NAC) combined with fluid resuscitation on pulmonary cell death in rats induced with controlled hemorrhagic shock (HS). METHODS: Two arteries (MAP calculation and exsanguination) and one vein (treatments) were catheterized in 22 anesthetized rats. Two groups of male albino rats were induced with controlled HS at 35mmHg MAP for 60 min. After this period, the RL group was resuscitated with Ringer's lactate and the RL+NAC group was resuscitated with Ringer's lactate combined with 150mg/Kg NAC. The control group animals were cannulated only. The animals were euthanized after 120 min of fluid resuscitation. Lung tissue samples were collected to evaluate the following: histopathology, TUNEL and imunohistochemical expression of caspase 3. RESULTS: RL showed a greater number of cells stained by TUNEL than RL + NAC, but there was no change in caspase 3 expression in any group. CONCLUSION: N-acetylcysteine associate to fluid resuscitation, after hemorrhagic shock, decreased cell death attenuating lung injury.

OBJETIVO: Avaliar o efeito da N-acetilcisteína (NAC) combinada ao fluido de reposição volêmica na morte celular pulmonar de ratos submetidos ao choque hemorrágico (CH) controlado. MÉTODOS: Duas artérias (cálculo da PAM e exsanguinação) e uma veia (tratamentos) foram cateterizadas em 22 ratos anestesiados. Dois grupos de ratos machos albinos foram induzidos ao CH controlado com PAM de 35mmHg por 60 min. Após este período, o grupo RL foi ressuscitado com Ringer lactato e o grupo RL+NAC foi ressuscitado com Ringer lactato associado com 150mg/Kg de NAC. O grupo controle sofreu somente o procedimento cirúrgico de cateterização. Os animais sofreram eutanásia após 120 min. da ressuscitação. Amostras de tecido pulmonar foram coletadas para histopatologia, TUNEL e a imuno-expressão da caspase 3. RESULTADOS: RL apresentou maior número de células marcadas pelo TUNEL do que RL+NAC, porém sem alteração na expressão da caspase 3 em nenhum dos grupos estudados. CONCLUSÃO: A N-acetilcisteína teve um papel protetor na morte celular em modelo de choque hemorrágico controlado.

Impact of Plasma-Lyte pH 7.4 on acid-base status and hemodynamics in a model of controlled hemorrhagic shock

OBJECTIVE: Intravenous infusion of crystalloid solutions is a cornerstone of the treatment of hemorrhagic shock. However, crystalloid solutions can have variable metabolic acid-base effects, perpetuating or even aggravating shock-induced metabolic acidosis. The aim of this study was to compare, in a controlled volume-driven porcine model of hemorrhagic shock, the effects of three different crystalloid solutions on the hemodynamics and acid-base balance. METHODS: Controlled hemorrhagic shock (40 percent of the total blood volume was removed) was induced in 18 animals, which were then treated with normal saline (0.9 percent NaCl), Lactated Ringer's Solution or Plasma-Lyte pH 7.4, in a blinded fashion (n = 6 for each group). Using a predefined protocol, the animals received three times the volume of blood removed. RESULTS: The three different crystalloid infusions were equally capable of reversing the hemorrhage-induced low cardiac output and anuria. The Lactated Ringer's Solution and Plasma-Lyte pH 7.4 infusions resulted in an increased standard base excess and a decreased serum chloride level, whereas treatment with normal saline resulted in a decreased standard base excess and an increased serum chloride level. The Plasma-Lyte pH 7.4 infusions did not change the level of the unmeasured anions. CONCLUSION: Although the three tested crystalloid solutions were equally able to attenuate the hemodynamic and tissue perfusion disturbances, only the normal saline induced hyperchloremia and metabolic acidosis.

Modulación inflamatoria en el shock traumático: [revisión] / Inflammatory modulation in traumatic shock: [review]

Hemorrhagic hypovolemic shock secondary to trauma is an important cause of morbidity and mortality worldwide. During the last few years, new concepts have emerged and the guidelines of fluid resuscitation in these patients have been redefined. The concept of hypotensive resuscitation has been established and new colloid solutions based on starch have been manufactured, been hydroxyethyl starch in a balanced electrolytic solution, the most studied and successful one. It has been reported, as well, the positive effects of the pharmacologic modulation of the inflammatory pathways in experimental model subjects submitted to hypovolemic shock. Products such as, ethyl pyruvate and the Na+/H+ type 1 inhibitor, BIIB513, have been Studies only experimentally in rodent models using colloids as the primary resuscitation fluid. The significant improvement in the hemodinamyc, pattern and the cardiac and inflammatory indexes and mediators, has created the basis for their use in clinical trials in the near future. The systemic inflammatory response is an important cause of multiple organ failure that increases the late mortality of patients surviving the initial early phases of hypovolemic traumatic shock and its experimental modulation in rodent models with products such as ethyl pyruvate and BIIB513 has produced excellent in vivo and in vitro results.

Universalmente se considera el Shock hipovolémico de origen hemorrágico como una importante causa de morbi-mortalidad. Durante los últimos años se ha redefinido los conceptos de la reanimación con líquidos intravenosos en los pacientes con choque hipovolémico y establecido los conceptos de reanimación hipotensa con el uso de nuevos coloides derivados del almidón, tales como el hidroxietil-almidón en solución electrolítica balanceada (Hextend®). Así mismo, se ha reportado el beneficio que conlleva el uso de modificadores de la cascada inflamatoria en modelos experimentales de sujetos sometidos a choque hipovolémico hemorrágico. Productos como el etil piruvato y la BIIB513, un inhibidor selectivo del intercambiador Na+/H+ tipo 1, han sido estudiados sólo experimentalmente en modelos roedores, empleando coloides como principal elemento de reanimación. Al mejorar el perfil hemodinámico, parámetros cardíacos y niveles de mediadores inflamatorios, estos compuestos constituyen una base cierta para ser incluidos en estudios clínicos en un futuro próximo. La respuesta inflamatoria sistémica está íntimamente implicada en la patogénesis de la Falla Orgánica Múltiple, aumentando la mortalidad tardía de pacientes que sobreviven las etapas tempranas del shock hipovolémico hemorrágico traumático. Su modulación experimental con el etil piruvato o bien la BIIB513 ha dado excelente resultado tanto en modelos experimentales in vivo como in vitro.

Cardiocirculatory changes in hemorrhagic shock induced in pigs submitted to three distinct therapeutic methods / Alterações cardiocirculatórias no choque hemorrágico induzido em suínos submetidos a três terapias distintas

PURPOSE: To evaluate and compare the response of pigs submitted to hemorrhagic shock and treated using three different strategies. METHODS: Thirty-five Dalland pigs were divided into four groups: Control; Bleeding; Saline and Saline + Red Cell Concentrate. Parameters evaluated: heart rate (HR), mean arterial blood pressure (MAP) and central vein pressure (CVP).Hemorrhagic shock was induced by removing (624.25±64.55), (619.30±44.94) and (664.23±39.96) ml of blood respectively, with the following treatment: Bleeding Group - zero volume replacement; Saline Group - replacement with 676 ml of 0.9 percent saline solution; Saline + Red Cell Concentrate Group - replacement with 440 ml of 0.9 percent saline solution + 291 ml of red cell concentrate. The treatment was evaluated after 10 (T3), 30 (T4), 45 (T5) and 60 (T6) minutes. RESULTS: HR: No statistically significant difference was found between the Bleeding and Saline [p=1.000], Bleeding and Saline + Red Cell Concentrate [p=1.000], and Saline and Saline + Red Cell Concentrate [p=0.721] groups. MAP; Significant differences were found between all the groups studied. CVP: No significant difference was found between the groups. CONCLUSION: Non-replacement and euvolemic resuscitation maintained a satisfactory hemodynamic pattern in controlled severe hemorrhagic shock in swine. The euvolemic replacement strategies exceeded the limit values of MAP for rebleeding.

OBJETIVO: Avaliar e comparar as respostas cardiocirculatórias em suínos tratados por três terapias diferentes após choque hemorrágico. MÉTODOS: Trinta e cinco suínos Dalland foram divididos em quatro grupos: Controle; Sangria; Salina; Salina + Concentrado de hemácias. Parâmetros cardiocirculatórios avaliados: Frequência cardíaca (FC), pressão arterial média (PAM) e pressão venosa central (PVC). O choque hemorrágico foi induzido retirando (624,25±64,55) (619,30±44,94) e (664,23±39,96) ml do volume sanguíneo. Terapias: Grupo Sangria - Sem reposição volêmica; Grupo Salina - reposição com 676 ml de solução salina 0.9 por cento; Grupo Salina + Concentrado de hemácias - reposição com 440 ml de solução salina 0,9 por cento + 291 ml de concentrado de hemácias. A avaliação do tratamento foi realizada aos 10 (T3), 30 (T4), 45 (T5) e 60 minutos (T6). RESULTADOS: FC; Não houve diferença significativa entre os grupos Sangria e Salina [p=1,000]; Sangria e Salina + Concentrado de hemácias [p=1,000]; Salina e Salina + Concentrado de hemácias [p=0,721]. PAM; Houve diferença entre todos os grupos. PVC; Não houve diferença entre os grupos estudados. CONCLUSÃO: Os procedimentos sem reposição e com reposição euvolêmica mantiveram padrão hemodinâmico satisfatório no choque hemorrágico grave controlado em suínos. As estratégias de reposição euvolêmica ultrapassaram os valores de PAM considerados limites para o resangramento.

Blood loss and transcapillary refill in uncontrolled treated hemorrhage in dogs

Objetive: This study evaluated retroperitoneal hematomas produced by bilateral injury of iliac arteries (uncontrolled hemorrhage), blood volume loss, transcapillary refill, the effects of volume replacement on retroperitoneal bleeding and the hemodynamic changes with and without treatment. Methods: Initial blood volume was determined with Tc99m-labelled red cells, and bleeding was evaluated by means of a portable scintillation camera positioned over the abdomen. Previously splenectomized mongrel dogs (16.8 ± 2.2 kg) were submitted to hemorrhage for 30 minutes and randomized into three groups: I - no treatment (n=7); II - treatment with 32 mL/kg of Lactated Ringer's for three to five minutes (n=7); and III - treatment with 4 mL/kg of 7.5 percent NaCl plus 6.0 percent dextran 70 for three to five minutes (n=7). They were studied for an additional 45 minutes. Results: Volume replacement produced transitory recovery in hemodynamic variables, including mean pulmonary artery pressure, pulmonary capillary wedge pressure and cardiac index, with significant increase in dogs treated with 32 mL/kg of Lactated Ringer's and 7.5 percent NaCl plus 6.0 percent dextran 70 (p<0.001, against no treatment), along with a decrease (p<0.001) in the systemic vascular resistance index. Groups II and III had significant initial decreases in hematocrit and hemoglobin. The treated dogs (groups II and III) presented rebleeding, which was greater during treatment with 32 mL/kg of Lactated Ringer's (group II). Conclusions: Despite the rebleeding observed in treated groups, the utilization of hypertonic saline solution with dextran proved to be effective in the initial reanimation, producing evident transcapillary refill, while the Lactated Ringer's solution produced capillary extravasation and was ineffective in the initial volume replacement in this model of uncontrolled hemorrhage.

The Anti-Inflammatory Effects of Ulinastatin in Trauma Patients with Hemorrhagic Shock

We investigated the use of ulinastatin in association with the suppression of polymorphonuclear leukocyte elastase (PMNE), tumor necrosis factor alpha (TNF-alpha) and interleukin 6 (IL-6), and its effects on the prognosis of patients with traumatic hemorrhagic shock. Nineteen patients who visited the emergency department for traumatic hemorrhagic shock were enrolled. Eleven patients were randomly selected to receive a total of 300,000 IU of ulinastatin. Measurements of serum PMNE, TNF-alpha and IL-6 were taken before ulinastatin treatment at 24 hr, two days, three days, and seven days after admission. We compared the Systemic Inflammatory Response Syndrome scores, Multiple Organ Dysfunction Syndrome scores and Acute Physiology, age, Chronic Health Evaluation III scores of the control and ulinastatin groups. There were no significant differences in baseline values, laboratory data, treatment or mortality between the two groups. The serum PMNE levels in the ulinastatin group were lower than in the control group on the second hospitalized day. Serum TNF-alpha and IL-6 levels in the ulinastatin group decreased 24 hr after admission but had no significance. It is suggested that ulinastatin treatment could decrease the serum PMNE levels in trauma patients with hemorrhagic shock at 48 hr after treatment.

Treatment of hemorrhagic shock with hypertonic saline solution modulates the inflammatory response to live bacteria in lungs

Shock and resuscitation render patients more susceptible to acute lung injury due to an exacerbated immune response to subsequent inflammatory stimuli. To study the role of innate immunity in this situation, we investigated acute lung injury in an experimental model of ischemia-reperfusion (I-R) followed by an early challenge with live bacteria. Conscious rats (N = 8 in each group) were submitted to controlled hemorrhage and resuscitated with isotonic saline (SS, 0.9 percent NaCl) or hypertonic saline (HS, 7.5 percent NaCl) solution, followed by intratracheal or intraperitoneal inoculation of Escherichia coli. After infection, toll-like receptor (TLR) 2 and 4 mRNA expression was monitored by RT-PCR in infected tissues. Plasma levels of tumor necrosis factor α and interleukins 6 and 10 were determined by ELISA. All animals showed similar hemodynamic variables, with mean arterial pressure decreasing to nearly 40 mmHg after bleeding. HS or SS used as resuscitation fluid yielded equal hemodynamic results. Intratracheal E. coli inoculation per se induced a marked neutrophil infiltration in septa and inside the alveoli, while intraperitoneal inoculation-associated neutrophils and edema were restricted to the interseptal space. Previous I-R enhanced lung neutrophil infiltration upon bacterial challenge when SS was used as reperfusion fluid, whereas neutrophil influx was unchanged in HS-treated animals. No difference in TLR expression or cytokine secretion was detected between groups receiving HS or SS. We conclude that HS is effective in reducing the early inflammatory response to infection after I-R, and that this phenomenon is achieved by modulation of factors other than expression of innate immunity components.

Effects of adenosine on the organ injury and dysfunction caused by hemorrhagic shock

Adenosine has been shown in animal and human studies to decrease the post-ischemic myocardial injury by lowering the levels of tumor necrosis factor-a. The objectives of the study was to examine the protective effects of adenosine on the organ injury [liver, kidney, pancreas] associated with hemorrhagic shock in rats. The study was conducted at Cardiovascular Physiology laboratory, King Saud University, Riyadh in 2007-2008. Anesthetized male Sprague- Dawley rats were assigned to hemorrhage and resuscitation treated with 20mM adenosine, untreated, or similar time matched control groups [n=6 per group]. Rats were hemorrhaged for one hour using a reservoir model. Arterial blood pressure was monitored for one hour, and maintained at a mean arterial blood pressure of 40 mmHg. Adenosine 20mM was injected intra-arterially, before resuscitation in the adenosine treated group. Resuscitation was performed by reinfusion of the sheded blood for 30 minutes. Arterial blood samples were analyzed for biochemical indicators of multiple organ injury: 1] liver function: aspartate aminotransferase [AST], alanine aminotransferase [ALT], 2] renal function: urea and creatinine, 3] pancreatic function: amylase. In the control group there was no significant rise in the serum levels of [i] urea and creatinine, [ii] aspartate aminotransferase [AST] and alanine aminotransferase [ALT], [iii] amylase. While in the adenosine treated group, resuscitation from one hour of hemorrhagic shock resulted in significant rises in the serum levels of [i] urea and creatinine, [ii] aspartate aminotransferase [AST] and alanine aminotransferase [ALT], [iii] amylase. Treatment of rats with 20mM adenosine before resuscitation following one hour of hemorrhagic shock decreased the multiple organ injury and dysfunction caused by hemorrhagic shock. Adenosine attenuated the renal, liver and pancreatic injury caused by hemorrhagic shock and resuscitation in rats. Thus, the inflammatory response to shock may contribute to the multiple organ failure developed after hemorrhagic shock and resuscitation

Donador exógeno de óxido nítrico en la respuesta inflamatoria hepática y hemodinámica después de choque hemorrágico / Exogenous nitric oxide donor in the liver inflammatory and hemodynamic response after hemorrhagic shock

BACKGROUND: Hemorrhagic shock (HS) results in oxidative stress to cells and in the induction of the inflammatory response, with an increased expression of a number of proinflammatory mediators and cytokines. We tested the ability of the nitric oxide (NO) donor sodium nitroprusside (NP) to reduce tissue injury in a rodent model of uncontrolled hemorrhagic shock. METHODS: Seventy two Sprague Dawley rats weighing 250-300 g were subjected to a model of uncontrolled hemorrhagic shock. Four groups of animals were included (n = 18 per group): sham/saline, sham/NP, shock/saline, shock/NP. Experimental design consisted of the development of hemorrhagic shock (3 ml/100 g) in a 15-min period, tail amputation (75%) and drug administration at 30 min, fluid resuscitation (FR) with Ringer's lactate (RL) solution to reach a mean arterial pressure (MAP) of 40 mmHg, a hospital phase of 60 min with hemostasis and FR with LR solution to reach a MAP of 70 mmHg, and a 3-day observation phase. Treatment at the beginning of resuscitation included either normal saline (groups 1, 3) or NP (0.5 mg/kg) (groups 2, 4). The following parameters were evaluated: fluid requirements for resuscitation, liver injury tests, liver tissue myeloperoxidase (MPO), liver histology, and 3-day survival. RESULTS: NP significantly reduced fluid requirements for resuscitation (p = 0.0001). We also observed an improved statistically significant difference in tests demonstrating hepatic injury (p = 0.0001), neutrophil infiltration as evidences by liver MPO (p <0.05), and histology studies (p = 0.001). Survival was also increased from 40% in controls to 60% with NP treatment. CONCLUSIONS: These data suggest that excess NO mediates hemorrhage-induced liver injury, and that the suppression of NO with NP may reduce the pathological consequences of severe hemorrhage, possibly by scavenging superoxide (O(2)(-)), thus limiting the production of more aggressive radicals.

Responsiveness to different volume therapies following hemodilution and hemorrhagic shock: a comparative experimental study in rats

Guidelines for volume replacement for acutely hemorrhaged and hemodiluted trauma patients have not been well established. Purpose: To evaluate the effects of acute hemodilution on mean arterial pressure (MAP), and responsiveness of acutely hemodiluted and subsequently hemorrhaged rats to different volume therapies. Methods: 180 rats were hemodiluted to simulate hemorrhaged trauma patients with persistent bleeding after high volume replacement with isotonic solutions. Thirty hemodiluted [Anemia (ANE) group] animals received no further treatment. The remaining 150 animals were subjected to hypovolemic shock and randomized into five groups, according to the treatment option employed: Control (CTL) animals did not receive subsequent treatment after hemorrhagic hypovolemia, SAL4 animals received isotonic saline 4 mL/kg, SAL32 animals received isotonic saline 32 mL/kg, HS animals received hypertonic saline 4 mL/kg and BLD animals received re-infusion of drawn blood. Results: Highest mean arterial pressure (MAP) was achieved by BLD, followed by SAL32 and HS. MAP after treatment of BLD, HS, SAL32 and ANE were higher than CTL (p=0.036). At 85 and 95 minutes of experiment, SAL4, SAL32 and HS presented the lowest hematocrit levels (p<0.01). At day 3, ANE, CTL and HS had the highest hematocrit. SAL4 and CTL groups presented the highest mortality rates. Conclusion: Hypertonic saline is an effective and safe initial therapy for hemodiluted rats undergoing hemorrhagic shock, with an overall outcome comparable to blood replacement or high volume isotonic saline administration.

A conduta para reposição volêmica em pacientes traumatizados, hemodiluídos não está bem estabelecida. Objetivo: Avaliar o efeito da hemodiluição sobre a pressão arterial média (PAM), bem como a resposta de ratos agudamente hemodiluídos e submetidos a choque hemorrágico, à reanimação com diferentes soluções. Métodos: 180 ratos foram hemodiluídos, simulando pacientes traumatizados com sangramento persistente após reposição com soluções isotônicas. Trinta ratos hemodiluídos (grupo ANE) foram observados, sem tratamento. Os demais 150 foram submetidos a choque hipovolêmico e randomizados em 5 grupos segundo a opção terapêutica: CTL (controle), sem tratamento subseqüente após hipovolemia hemorrágica; SAL4 que recebeu 4 mL/kg de salina isotônica; SAL32 que recebeu 32 mL/kg de salina isotônica ; SH que recebeu 4mL/kg de salina hipertônica; e BLD que recebeu reinfusão do sangue removido. Resultados: A pressão arterial média (PAM) mais alta ocorreu no grupo BLD, seguida pelo SAL32, e SH. A PAM após tratamento nos grupos BLD, SH, SAL32 e ANE foram maiores que no CTL (-=0.036). Aos 85 e 95 minutos do experimento, SAL4, SAL32, e SH apresentaram os menores hematócritos (p<0.01). No 3° dia, ANE, CTL e SH apresentaram os maiores hematócritos. SAL4 e CTL apresentaram as maiores taxas de mortalidade. Em conclusão, nossos resultados indicam que a SH é uma terapia inicial efetiva e segura em ratos hemodiluídos, submetidos a hemorrágico choque, com prognóstico comparável à reposição com sangue ou administração de grande volume de solução isotônica.

Gender and sex hormones influence the response to trauma and sepsis: potential therapeutic approaches

Several clinical and experimental studies have demonstrated gender dimorphism in immune and organ responsiveness and in the susceptibility to and morbidity from shock, trauma, and sepsis. In this respect, cell-mediated immune responses have been shown to be depressed in males following trauma-hemorrhage, whereas they were aintained/enhanced in proestrus females. Furthermore, sex hormones have been shown to be responsible for this gender-specific immune response following adverse circulatory conditions. More specifically, studies indicate that androgens produce immunodepression following trauma-hemorrhage in males. In contrast, female sex steroids appear to exhibit immunoprotective properties following trauma and severe blood loss. With regard to the underlying mechanisms, receptors for sex hormones have been identified on various immune cells suggesting direct effects of these hormones on the immune cells. Alternatively, indirect effects of sex hormones, ie, modulation of cardiovascular responses or androgen- and estrogen-synthesizing enzymes, might contribute to gender-specific immune responses. Recent studies indicate that sex hormones, eg, dehydroepiandrosterone (DHEA), also modulate the function of peripheral blood mononuclear cells in surgical patients. Thus, the immunomodulatory properties of sex hormones/receptor antagonists/sex steroid synthesizing enzymes following trauma-hemorrhage suggests novel therapeutic strategies for the treatment of immunodepression in surgical patients.

Uma série de estudos clínicos e experimentais demonstram a existência de dimorfismo sexual das respostas imunológicas e orgânicas, bem como da suscetibilidade e morbidade em relação ao choque, ao trauma e à sepse. Respostas imunes celularmente mediadas apresentam-se deprimidas em machos em resposta ao binômio trauma-hemorragia, mas conservados/enaltecidos em fêmeas em proestro. Adicionalmente demonstra-se que os hormônios sexuais são responsáveis por esta dicomotomia de resposta sexualmente específica, em condições cardiovasculares adversas. Estudos específicos indicam que os andrógenos produzem imunodepressão pós-trauma hemorragia em machos. Em contraste, esteróides sexuais femininos parecem exibir propriedades imunoprotetoras após episódios de trauma com ou sem perda importante de sangue. No terreno dos mecanismos subjacentes, foram identificados receptores para hormônios sexuais em várias células do sistema imunológico, sugerindo a existência de efeitos diretos destes hormônios sobre tais células. Alternativamente, observam efeitos indiretos de hormônios sexuais tais como modulação das respostas cardiovasculares das enzimas sintetizadores de andrógeno e estrógeno, que podem contribuir para as estas respostas sexualmente diferenciadas. Estudos recentes indicam que os hormônios sexuais, como por exemplo a dehidroepiandrosterona também modulam a função de células mononucleares da série branca em pacientes cirúrgicos. Assim, as propriedades imunomodulatórias de hormônios sexuais/antagonistas de receptores/enzimas sintetizadores de esteróides após a ocorrência de trauma ou de hemorragia sugerem o caminho para novas estratégias terapêuticas para o tratamento de imunodepressão em pacientes cirúrgicos.

Reposiçäo volêmica no choque hemorrágico: a soluçäo empregada faz diferença em relaçäo aos efeitos hemodinâmicos e renais? / Hemorrhagic shock volume replacement: does the solution make a difference in hemodynamic and renal effects?

Justificativa e objetivos - O emprego de pequenos volumes de soluçäo hipertônica (SH) isoladamente ou em associaçäo à soluçäo de dextran 70 a 6 por cento (SHD), abre novas perpectivas no manuseio da reposiçäo volêmica durante o choque hipovolêmico, em relaçäo ao emprego de soluçöes cristalóides. A pesquisa experimental tem como objetivo verificar se o tipo de soluçäo empregada na reposiçäo do choque hemorrágico apresenta alguma diferença em relaçäo aos efeitos hemodinâmicos e renais. Método - Foram utilizados 24 cäes anestesiadoscom pentobarbital sódico. Após retirada de 40 por cento do volume sanguíneo, os cäes foram distribuídos de forma aleatória em grupos de 8 animais, de acordo com a soluçäo empregada para a reposiçäo volêmica: G1 - SH a 7,5 por cento em volume de 4ml.kg-1; G2 - soluçäo de Ringer com lactato (RL) na proporçäo 2:1 em relaçäo ao volume de sangue retirado; e G3 - SHD em volume de 4ml.kg-1. Foram estudados os seguintes atributos: frequência cardíaca (FC), pressäo arterial média (PAM), pressäo venosa central (PVC), fluxo sanguíneo aortico (FAo), resistência vascular aórtica (RvAo), fluxo plasmático renal (FPR), ritmo de filtraçäo glomerular (RFG), fluxo sanguíneo renal, débito urinário (DU), resistência vascular renal, excreçäo urinária de sódio (EFNa), depuraçäo osmolar (Dosm) e depuraçäo de água livre (DH2O). Os atributos PAM, PVC, FAo foram estudados nos momentos: M1 (controle); M2 - após a retirada dos 40 por cento da volemia; M3, M4 e M5 - imediatamente e após 15 e 60 min da reposiçäo volêmica, respectivamente. Os demais atributos estudados nos momentos: M1 (controle); M2 e M3-15 e 60 min da reposiçäo volêmica, respectivamente. Resultados - A reposiçäo com RL (G2) aumentou o FAo e a PVC em M3 e M4, em níveis superiores aos determinados pela reposiçäo com pequenos volumes (G1 e G3). Näo houve diferença significante da PAM entre os grupos, que se elevou após a reposiçäo, mas näo retornou aos níveis do controle. O DU aumentou significativamente em G2 (RL), com aumento da DH2O nesse grupo em G3 (SHD). Conclusöes - A reposiçäo com RL determina excessiva expansäo volêmica, enquanto a reposiçäo com SH e SDH determina boa expansäo volêmica, sem diferença significante entre elas. Todas as soluçöes mantêm a hemodinâmica e funçäo renais, com o RL provocando aumento do débito urinário

Vision historica del shock / Historical vision of shock

El concepto de shock y su estrecha relación con el de stress surgió a partir de los trabajos de Hans Selye iniciados en 1936 en la Universidad de McGill en Montreal, con quien colaboré entre 1939 y 1942. Se demonstró que el síndrome general de adaptación se inicia con la reacción de alarma, compuesta por una etapa de shock y una de contra-shock, seguida de la etapa de resistencia y finalmente de la de agotamiento. Mi tesis doctoral concluía que el shock se debía a una insuficiencia suprarrenal aguda postulándose que procesos metabólicos activos hacían desaparecer compuestos esenciales para la sobrevida. Mi interés en la relación del shock con los hidratos de carbono me llevó en 1942 a trabajar con Bernardo Houssay en el Instituto de Fisiología de la Universidad de Buenos Aires y luego en 1944 con C.N.H. Long en la Universidad de Yale. Allí desarrolé un método para inducir el shock hemorrágico en el cobayo con una letalidad del 94 por ciento; llamativamente, con la administración de 200 mg de ácido ascórbico se prevenía la muerte. Al trasladarme definitivamente a Buenos Aires, estos resultados se confirmaron y además se consiguió un 40 por ciento de sobrevida con cortisona mientras que la desoxicorticosterona carecía de efecto. En aquel entonces no tuvimos explicación para la muerte por shock hemorrágico, pero hoy, medio siglo más tarde, de este Simposio debería surgir el mecanismo involucrado.

The crystalloid vs colloid controversy in the era os hypertonic/hyperoncotic resuscitations: is the debate over?

The crystalloid vs. colloid controversy has been further complicated by the inclusion of hypertonic levels of sodium chloride (HTS) in both types of regimens. In this paper the recent literature on the controversy is reviewed. Colloids raise the intravascular colloid osmotic pressure and increase the fluid retention in the vessels. Crystalloids however, distribute into the interstitial and intravascular spaces at a ratio of approximately 3 to 1. It is therefore necessary to infuse a large volume of crystalloids in order to complete resuscitation. The advantage of colloids over isotonic crystalloids focuses primarily on the incidence of pulmonary edema. In an analysis of clinical trials, however, colloids were not proven to be superior to crystalloids. The use of HTS decreases the amount of crystalloid required for resuscitation. Pulmonary and systemic vasodilation, an increase in cardiac output and stroke volume, decreased intracranial pressure and an enhanced immunologic response have been noted experimentally, and the clinical evidence seems to corroborate these findings. HTS with dextran (HSD) has been used in an attempt to combine the rapid cellular fluid shift of hypertonicity with the vascular fluid shift of colloids. The experimental evidence is compelling. Whereas HTS has proven itself to be a superior resuscitation regimen, HSD has not yet warranted in a clinical setting the optimism which its experimental studies seem to indicate.