Resuscitation speed affects brain injury in a large animal model of traumatic brain injury and shock

Abstract

BackgroundOptimal fluid resuscitation strategy following combined traumatic brain injury (TBI) and hemorrhagic shock (HS) remain controversial and the effect of resuscitation infusion speed on outcome is not well known. We have previously reported that bolus infusion of fresh frozen plasma (FFP) protects the brain compared with bolus infusion of 0.9% normal saline (NS). We now hypothesize reducing resuscitation infusion speed through a stepwise infusion speed increment protocol using either FFP or NS would provide neuroprotection compared with a high speed resuscitation protocol.Methods23 Yorkshire swine underwent a protocol of computer controlled TBI and 40% hemorrhage. Animals were left in shock (mean arterial pressure of 35 mmHg) for two hours prior to resuscitation with bolus FFP (n = 5, 50 ml/min) or stepwise infusion speed increment FFP (n = 6), bolus NS (n = 5, 165 ml/min) or stepwise infusion speed increment NS (n = 7). Hemodynamic variables over a 6-hour observation phase were recorded. Following euthanasia, brains were harvested and lesion size as well as brain swelling was measured.ResultsBolus FFP resuscitation resulted in greater brain swelling (22.36 ± 1.03% vs. 15.58 ± 2.52%, p = 0.04), but similar lesion size compared with stepwise resuscitation. This was associated with a lower cardiac output (CO: 4.81 ± 1.50 l/min vs. 5.45 ± 1.14 l/min, p = 0.03). In the NS groups, bolus infusion resulted in both increased brain swelling (37.24 ± 1.63% vs. 26.74 ± 1.33%, p = 0.05) as well as lesion size (3285.44 ± 130.81 mm3 vs. 2509.41 ± 297.44 mm3, p = 0.04). This was also associated with decreased cardiac output (NS: 4.37 ± 0.12 l/min vs. 6.35 ± 0.10 l/min, p < 0.01).ConclusionsIn this clinically relevant model of combined TBI and HS, stepwise resuscitation protected the brain compared with bolus resuscitation.

Outcomes after concomitant traumatic brain injury and hemorrhagic shock

“…26 Speed of resuscitation may also be imperative for protecting brain function; animal models using a stepwise ratio-guided protocol with FFP (compared to a bolus protocol) have demonstrated a neuroprotective effect. 27 Additional pharmacologic modalities, such as valproic acid 28,29 and hypertonic saline 30 continue to be studied for the prevention of cerebral metabolic derangements and excitotoxicity in patients with TBI + HS.…”

The use of crystalloids in traumatic brain injury

“…A quick infusion of crystalloids or plasma not only increases the risk for ARDS, but also for brain oedema. An experimental study has documented that rapid infusion of crystalloids and plasma following TBI and shock has been associated with brain swelling and an increase in ICP despite quick correction of peripheral oxygenation and cardiac output [53]. Moreover, fast infusion of crystalloid solutions has increased lesion size.…”

Management of Castor Bean Seed-Associated Intraventricular Hemorrhage with Fresh Frozen Plasma: A Case Report

“…The dramatic change observed in the patient conditions after FFP therapy, might be due to resuscitation with FFP, which attenuates both lesion size and fluid extravasation in the brain tissue, as it has been reported by Sillesen et al (2014) (21).…”