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Evaluation of prolonged 'Permissive Hypotension': results from a 6-hour hemorrhage protocol in swine.
Trauma Surg Acute Care Open 2019; 4(1):e000369TS

Abstract

Background

Tactical Combat Casualty Care guidelines for hemorrhage recommend resuscitation to systolic blood pressure (SBP) of 85±5 mm Hg during prehospital care. Success depends on transport to definitive care within the 'golden hour'. As future conflicts may demand longer prehospital/transport times, we sought to determine safety of prolonged permissive hypotension (PH).

Methods

Adult male swine were randomized into three experimental groups. Non-shock (NS)/normotensive underwent anesthesia only. NS/PH was bled to SBP of 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by 6 hours of PFC. Hemorrhaged animals were then resuscitated with whole blood and observed for 24 hours. Physiologic variables, blood, tissue samples, and neurologic scores were collected.

Results

Survival of all groups was 100%. Fluid volumes to maintain targeted SBP in PFC were significantly higher in the hemorrhage group than sham groups. After 24 hours' recovery, no significant differences were observed in neurologic scores or cerebrospinal fluid markers of brain injury. No significant changes in organ function related to treatment were observed during PFC through recovery, as assessed by serum chemistry and histological analysis.

Conclusions

After 6 hours, a prolonged PH strategy showed no detrimental effect on survival or neurologic outcome despite the increased ischemic burden of hemorrhage. Significant fluid volume was required to maintain SBP-a potential logistic burden for prehospital care. Further work to define maximum allowable time of PH is needed.

Study type

Translational animal model.

Level of evidence

N/A.

Authors+Show Affiliations

Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA.Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA.Division of Trauma Critical Care, San Antonio Military Medical Center, San Antonio, Texas, USA.Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA.Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA.Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA.Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, San Antonio, Texas, USA. Division of Trauma Critical Care, San Antonio Military Medical Center, San Antonio, Texas, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31803845

Citation

Morgan, Clifford G., et al. "Evaluation of Prolonged 'Permissive Hypotension': Results From a 6-hour Hemorrhage Protocol in Swine." Trauma Surgery & Acute Care Open, vol. 4, no. 1, 2019, pp. e000369.
Morgan CG, Neidert LE, Hathaway EN, et al. Evaluation of prolonged 'Permissive Hypotension': results from a 6-hour hemorrhage protocol in swine. Trauma Surg Acute Care Open. 2019;4(1):e000369.
Morgan, C. G., Neidert, L. E., Hathaway, E. N., Rodriguez, G. J., Schaub, L. J., Cardin, S., & Glaser, J. J. (2019). Evaluation of prolonged 'Permissive Hypotension': results from a 6-hour hemorrhage protocol in swine. Trauma Surgery & Acute Care Open, 4(1), pp. e000369. doi:10.1136/tsaco-2019-000369.
Morgan CG, et al. Evaluation of Prolonged 'Permissive Hypotension': Results From a 6-hour Hemorrhage Protocol in Swine. Trauma Surg Acute Care Open. 2019;4(1):e000369. PubMed PMID: 31803845.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Evaluation of prolonged 'Permissive Hypotension': results from a 6-hour hemorrhage protocol in swine. AU - Morgan,Clifford G, AU - Neidert,Leslie E, AU - Hathaway,Emily N, AU - Rodriguez,Gerardo J, AU - Schaub,Leasha J, AU - Cardin,Sylvain, AU - Glaser,Jacob J, Y1 - 2019/11/21/ PY - 2019/08/16/received PY - 2019/10/11/revised PY - 2019/10/25/accepted PY - 2019/12/6/entrez KW - full resuscitation KW - hemorrhagic shock KW - hypotension KW - prolonged field care SP - e000369 EP - e000369 JF - Trauma surgery & acute care open JO - Trauma Surg Acute Care Open VL - 4 IS - 1 N2 - Background: Tactical Combat Casualty Care guidelines for hemorrhage recommend resuscitation to systolic blood pressure (SBP) of 85±5 mm Hg during prehospital care. Success depends on transport to definitive care within the 'golden hour'. As future conflicts may demand longer prehospital/transport times, we sought to determine safety of prolonged permissive hypotension (PH). Methods: Adult male swine were randomized into three experimental groups. Non-shock (NS)/normotensive underwent anesthesia only. NS/PH was bled to SBP of 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by 6 hours of PFC. Hemorrhaged animals were then resuscitated with whole blood and observed for 24 hours. Physiologic variables, blood, tissue samples, and neurologic scores were collected. Results: Survival of all groups was 100%. Fluid volumes to maintain targeted SBP in PFC were significantly higher in the hemorrhage group than sham groups. After 24 hours' recovery, no significant differences were observed in neurologic scores or cerebrospinal fluid markers of brain injury. No significant changes in organ function related to treatment were observed during PFC through recovery, as assessed by serum chemistry and histological analysis. Conclusions: After 6 hours, a prolonged PH strategy showed no detrimental effect on survival or neurologic outcome despite the increased ischemic burden of hemorrhage. Significant fluid volume was required to maintain SBP-a potential logistic burden for prehospital care. Further work to define maximum allowable time of PH is needed. Study type: Translational animal model. Level of evidence: N/A. SN - 2397-5776 UR - https://www.unboundmedicine.com/medline/citation/31803845/Evaluation_of_prolonged_'Permissive_Hypotension':_results_from_a_6-hour_hemorrhage_protocol_in_swine DB - PRIME DP - Unbound Medicine ER -