Abstract
Hemorrhagic shock is one of the leading causes of mortality and morbidity in pediatric trauma. Current treatment based on volume resuscitation is associated to adverse effects, and it has been proposed that vasopressors may be used in the pharmacological management of trauma. Terlipressin has demonstrated its usefulness in other pediatric critical care scenarios and its long half-life allows its use as a bolus in an outpatient critical settings. The aim of this study was to analyze whether the addition of a dose of terlipressin to the initial volume expansion produces an improvement in hemodynamic and cerebral perfusion at early stages of hemorrhagic shock in an infant animal model. We conducted an experimental randomized animal study with 1-month old pigs. After 30 minutes of hypotension (mean arterial blood pressure [MAP]<45 mmHg) induced by the withdrawal of blood over 30 min, animals were randomized to receive either normal saline (NS) 30 mL/kg (n = 8) or a bolus of 20 mcg/kg of terlipressin plus 30 mL/kg of normal saline (TP) (n = 8). Global hemodynamic and cerebral monitoring parameters, brain damage markers and histology samples were compared. After controlled bleeding, significant decreases were observed in MAP, cardiac index (CI), central venous pressure, global end-diastolic volume index (GEDI), left cardiac output index, SvO2, intracranial pressure, carotid blood flow, bispectral index (BIS), cerebral perfusion pressure (CPP) and increases in systemic vascular resistance index, heart rate and lactate. After treatment, MAP, GEDI, CI, CPP and BIS remained significantly higher in the TP group. The addition of a dose of terlipressin to initial fluid resuscitation was associated with hemodynamic improvement, intracranial pressure maintenance and better cerebral perfusion, which would mean protection from ischemic injury. Brain monitoring through BIS was able to detect changes caused by hemorrhagic shock and treatment.
Highlights
Hemorrhage is the most prevalent cause of shock in injured children, being trauma one of the most common causes
Controlled hemorrhage resulted in a significant decrease in Mean arterial blood pressure (MAP), cardiac index (CI), central venous pressure (CVP), global end-diastolic volume index (GEDI) and Left cardiac output index (LCOI) with a significant increase in Systemic vascular resistance index (SVRI) and HR in both groups (Table 1)
The addition of one dose of TP to initial resuscitation with fluids resulted in a hemodynamic improvement
Summary
Hemorrhage is the most prevalent cause of shock in injured children, being trauma one of the most common causes. Numerous clinical studies in adult humans and in animal models have shown that an approach involving early aggressive fluid resuscitation can have negative effects (such as dilution of coagulation factors, clot destabilization, increased bleeding, worsening of acidosis and severe hemodilution), that will reduce the oxygen supply to tissues and increase mortality. For this reason, we must develop new strategies that, avoiding the negative effects of aggressive fluid therapy, allow us to restore adequate tissue perfusion even in the initial phases of prehospital care, giving patients time to be transferred to a trauma center to receive definitive hemostatic and surgical treatment
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