Does the pediatric hemodynamic cliff exist in response to hemorrhagic shock?

Abstract

BackgroundThe paradigm that children maintain normal blood pressure during hemorrhagic shock until 30%–45% hemorrhage is widely accepted. There are minimal data supporting when decompensation occurs and how a child's vasculature compensates up to that point. We aimed to observe the arterial response to hemorrhage and when mean arterial pressure (MAP) decreased from baseline in pediatric swine. MethodsPiglets were hemorrhaged in 20% increments of their total blood volume to 60%. MAP and angiograms of the thoracic aorta (TA) and abdominal arteries were obtained. Percent change in area of the vessels from baseline was calculated. ResultsPiglets (n = 8) had a differential vasoconstriction starting at 20% hemorrhage (celiac artery 36.3% [31.4–44.6] vs TA 16.7% [10.7–19.1] p = 0.0012). At 40% hemorrhage, the differential vasoconstriction favored shunting blood away from the abdominal visceral branches to the TA (celiac artery 54.7% [36.9–60.6] vs TA 29.5% [23.9–36.2] p = 0.0056 superior mesenteric artery 46.7% [43.9–68.6] vs TA 29.5% [23.9–36.2] p = 0.0100). This was exacerbated at 60% hemorrhage. MAP decreased from baseline at 20% hemorrhage (66.4 ± 6.0 mmHg vs 41.4 ± 10.4 mmHg, p < 0.0001), and worsened at 40% and 60% hemorrhage. ConclusionIn piglets, a differential vasocontriction shunting blood proximally occurred in response to hemorrhage. This did not maintain normal MAP at 20%, 40% or 60% hemorrhage. Level of evidenceLevel II.