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Hemorrhagic Shock Increases Gut Luminal Cytokine Levels
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
43.4. The Early Post-Hemorrhage Coagulation Profile Is Characterized By Qualitative Platelet Dysfunction. A. A. Strawn,1,2,3 P. F. Hwang,1,2,3 E. A. Elster,1,2,3,4 D. K. Tadaki,3,4 F. R. Sheppard1,2,3,4; 1National Naval Medical Center, Bethesda, MD; 2Walter Reed Army Medical Center, Washington, DC; 3Naval Medical Research Center, Silver Spring, MD; 4Uniformed Services University of the Health Sciences, Bethesda, MD Introduction: The coagulopathy of trauma remains to be fully elucidated. During our group’s development of a Rhesus Macaque model of hemorrhagic shock, an isolated qualitative platelet dysfunction from baseline was suggested; this observation is supported by, limited, clinical reports dating to the Vietnam era. Our group proposed to further investigate the acute coagulopathy of hemorrhage and hypothesized that qualitative platelet dysfunction is an early component of the post-hemorrhage coagulation profile. Methods: Rhesus Macaques were anesthetized and a 60% transverse left hepatectomy performed (T¼0) with no attempt at hemorrhage control to induce grade III hemorrhagic shock. Fifteen minutes after injury (T¼15), 50ml of normal saline (NS) or 2 3 1010 fresh apheresed human platelets (FAP) were administered. Subsequent volume resuscitation utilized NS per ATLS guidelines. At T¼120 laparotomy was performed, operative hemostasis achieved and blood loss measured. Physiologic parameters were continually monitored and ROTEM EXTEM and FIBTEM, CBC and ABG analysis performed through T¼480. Data analysis: paired sample t-test; results reported as mean (SEM). Results: Grade III hemorrhagic shock was induced by T¼5min as indicated by a reduction in MAP from T¼0 (p<0.05) with a blood loss index of 27.5% (2.6) in NS controls. ROTEM EXTEM analysis: significant increase in clot formation time (CFT) and reduction in a angle at T¼60-480 from baseline (p<0.05) in NS controls; FAP treated animals had no significant change in CFT or a angle T¼0-480. ROTEM FIBTEM analysis: No significant change in CFT or a angle in NS or FAP treated animals T¼0-480. Platelet count decreased significantly (p<0.05) at T¼360-480 in NS controls and at T¼180-480 in FAP treated. The controls also showed a significant decrease in hematocrit from T¼60 – 480. No significant difference within or between groups was identified with regards to temperature, ionized Ca, pH or volume administered T¼0-480. Mean fluid balance was greatest at T¼150: +15.95 (2.53) ml/ kg. Conclusions: Results demonstrate platelet dysfunction early (T¼60-480) following hemorrhagic shock as evidenced by isolated changes in ROTEM EXTEM a and CFT parameters from baseline in NS controls; these changes are avoided by FAP administration. No significant changes or differences, within or between NS and FAP groups, in temperature, pH or ionized calcium levels were observed. Furthermore, changes in platelet function occur prior to significant changes in platelet count and in the absence of clinical thrombocytopenia. In this Rhesus Macaque model, the early posthemorrhage coagulation profile is characterized by a qualitative platelet dysfunction. 43.5. Hemorrhagic Shock Increases Gut Luminal Cytokine Levels. D. I. Sonnier, A. T. Makley, L. W. Friend, S. R. Bailey, A. B. Lentsch, T. A. Pritts; Department of Surgery, University of Cincinnati, Cincinnati, OH
313
Introduction: Intestinal injury is a known consequence of hemorrhagic shock and resuscitation. The intestinal mucosa is increasingly recognized as an active participant in the immune response to ischemia/reperfusion injury, with production and secretion of multiple inflammatory mediators. Previous work in our laboratory indicates that intestinal epithelial cells secrete pro-inflammatory cytokines in the direction of both the lamina propria and intestinal lumen. In chronic intestinal inflammatory conditions such as Crohn’s disease, proinflammatory cytokines are present in significant amounts in the gut lumen and stool specimens, providing useful markers of disease severity. These luminal cytokines have been shown to influence intestinal healing and neutrophil migration and activation. The ability of the intestinal mucosa to transmit inflammatory signals via the gut lumen after hemorrhagic shock is unknown. We hypothesized that hemorrhagic shock results in secretion of proinflammatory cytokines into the gut lumen. Methods: Male C57/Bl6 mice underwent femoral artery cannulation and hemorrhage to a systolic blood pressure of 20 mm Hg. After one hour, the mice were resuscitated with normal saline. Sham animals were cannulated with no hemorrhage. Mice were decannulated and sacrificed at intervals. Stool was removed from cecum and colon, weighed, and placed into buffer solution. After incubating overnight at 4 C with gentle agitation, specimens were centrifuged and supernatants were analyzed via ELISA. Cytokine levels are expressed as picogram per gram of stool (pg/g stool). Results: When compared with sham-injured mice, hemorrhagic shock resulted in increased luminal cytokines. At three hours after injury, elevated levels of IL-6 were found in the lumen of the cecum, with TNFa and MIP-2 showing a similar but non-significant trend. At six hours after injury, TNFa, IL-6 and MIP-2 were significantly elevated in the cecal stool specimens (Figure) and IL-6 and MIP-2 were significantly elevated in the colonic lumen. Conclusions: Hemorrhagic shock results in significant increase of proinflammatory cytokines in the gut lumen. These findings suggest that the intestinal mucosa may transmit and receive signals in a paracrine fashion via the gut lumen.
43.6. Clot Strength On Arrival Is A Better Predictor Of Mortality Than Base Deficit In Patients Requiring Massive Transfusion. M. Pezold,1,2 M. Wohlauer,1,2 E. Gonzalez,1,2 A. Banerjee,2 C. Silliman,2 E. E. Moore1,2; 1Department of Surgery, Denver Health Medical Center, Denver, CO; 2 University of Colorado Denver, Aurora, CO Introduction: A third of seriously injured patients are coagulopathic on arrival to the ED. Recent evidence suggests this acute coagulopathy is due to endothelial ischemia. Base deficit is currently embraced as a sensitive marker of the depth of shock.
43.4. The Early Post-Hemorrhage Coagulation Profile Is Characterized By Qualitative Platelet Dysfunction. A. A. Strawn,1,2,3 P. F. Hwang,1,2,3 E. A. Elster,1,2,3,4 D. K. Tadaki,3,4 F. R. Sheppard1,2,3,4; 1National Naval Medical Center, Bethesda, MD; 2Walter Reed Army Medical Center, Washington, DC; 3Naval Medical Research Center, Silver Spring, MD; 4Uniformed Services University of the Health Sciences, Bethesda, MD Introduction: The coagulopathy of trauma remains to be fully elucidated. During our group’s development of a Rhesus Macaque model of hemorrhagic shock, an isolated qualitative platelet dysfunction from baseline was suggested; this observation is supported by, limited, clinical reports dating to the Vietnam era. Our group proposed to further investigate the acute coagulopathy of hemorrhage and hypothesized that qualitative platelet dysfunction is an early component of the post-hemorrhage coagulation profile. Methods: Rhesus Macaques were anesthetized and a 60% transverse left hepatectomy performed (T¼0) with no attempt at hemorrhage control to induce grade III hemorrhagic shock. Fifteen minutes after injury (T¼15), 50ml of normal saline (NS) or 2 3 1010 fresh apheresed human platelets (FAP) were administered. Subsequent volume resuscitation utilized NS per ATLS guidelines. At T¼120 laparotomy was performed, operative hemostasis achieved and blood loss measured. Physiologic parameters were continually monitored and ROTEM EXTEM and FIBTEM, CBC and ABG analysis performed through T¼480. Data analysis: paired sample t-test; results reported as mean (SEM). Results: Grade III hemorrhagic shock was induced by T¼5min as indicated by a reduction in MAP from T¼0 (p<0.05) with a blood loss index of 27.5% (2.6) in NS controls. ROTEM EXTEM analysis: significant increase in clot formation time (CFT) and reduction in a angle at T¼60-480 from baseline (p<0.05) in NS controls; FAP treated animals had no significant change in CFT or a angle T¼0-480. ROTEM FIBTEM analysis: No significant change in CFT or a angle in NS or FAP treated animals T¼0-480. Platelet count decreased significantly (p<0.05) at T¼360-480 in NS controls and at T¼180-480 in FAP treated. The controls also showed a significant decrease in hematocrit from T¼60 – 480. No significant difference within or between groups was identified with regards to temperature, ionized Ca, pH or volume administered T¼0-480. Mean fluid balance was greatest at T¼150: +15.95 (2.53) ml/ kg. Conclusions: Results demonstrate platelet dysfunction early (T¼60-480) following hemorrhagic shock as evidenced by isolated changes in ROTEM EXTEM a and CFT parameters from baseline in NS controls; these changes are avoided by FAP administration. No significant changes or differences, within or between NS and FAP groups, in temperature, pH or ionized calcium levels were observed. Furthermore, changes in platelet function occur prior to significant changes in platelet count and in the absence of clinical thrombocytopenia. In this Rhesus Macaque model, the early posthemorrhage coagulation profile is characterized by a qualitative platelet dysfunction. 43.5. Hemorrhagic Shock Increases Gut Luminal Cytokine Levels. D. I. Sonnier, A. T. Makley, L. W. Friend, S. R. Bailey, A. B. Lentsch, T. A. Pritts; Department of Surgery, University of Cincinnati, Cincinnati, OH
313
Introduction: Intestinal injury is a known consequence of hemorrhagic shock and resuscitation. The intestinal mucosa is increasingly recognized as an active participant in the immune response to ischemia/reperfusion injury, with production and secretion of multiple inflammatory mediators. Previous work in our laboratory indicates that intestinal epithelial cells secrete pro-inflammatory cytokines in the direction of both the lamina propria and intestinal lumen. In chronic intestinal inflammatory conditions such as Crohn’s disease, proinflammatory cytokines are present in significant amounts in the gut lumen and stool specimens, providing useful markers of disease severity. These luminal cytokines have been shown to influence intestinal healing and neutrophil migration and activation. The ability of the intestinal mucosa to transmit inflammatory signals via the gut lumen after hemorrhagic shock is unknown. We hypothesized that hemorrhagic shock results in secretion of proinflammatory cytokines into the gut lumen. Methods: Male C57/Bl6 mice underwent femoral artery cannulation and hemorrhage to a systolic blood pressure of 20 mm Hg. After one hour, the mice were resuscitated with normal saline. Sham animals were cannulated with no hemorrhage. Mice were decannulated and sacrificed at intervals. Stool was removed from cecum and colon, weighed, and placed into buffer solution. After incubating overnight at 4 C with gentle agitation, specimens were centrifuged and supernatants were analyzed via ELISA. Cytokine levels are expressed as picogram per gram of stool (pg/g stool). Results: When compared with sham-injured mice, hemorrhagic shock resulted in increased luminal cytokines. At three hours after injury, elevated levels of IL-6 were found in the lumen of the cecum, with TNFa and MIP-2 showing a similar but non-significant trend. At six hours after injury, TNFa, IL-6 and MIP-2 were significantly elevated in the cecal stool specimens (Figure) and IL-6 and MIP-2 were significantly elevated in the colonic lumen. Conclusions: Hemorrhagic shock results in significant increase of proinflammatory cytokines in the gut lumen. These findings suggest that the intestinal mucosa may transmit and receive signals in a paracrine fashion via the gut lumen.
43.6. Clot Strength On Arrival Is A Better Predictor Of Mortality Than Base Deficit In Patients Requiring Massive Transfusion. M. Pezold,1,2 M. Wohlauer,1,2 E. Gonzalez,1,2 A. Banerjee,2 C. Silliman,2 E. E. Moore1,2; 1Department of Surgery, Denver Health Medical Center, Denver, CO; 2 University of Colorado Denver, Aurora, CO Introduction: A third of seriously injured patients are coagulopathic on arrival to the ED. Recent evidence suggests this acute coagulopathy is due to endothelial ischemia. Base deficit is currently embraced as a sensitive marker of the depth of shock.