Selective aortic arch perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of noncompressible torso hemorrhage

Abstract

BACKGROUND Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC) after HiTCA, compared with resuscitative endovascular balloon occlusion of the aorta and cardiopulmonary resuscitation (CPR). Hemoglobin-based oxygen carriers, such as hemoglobin-based oxygen carrier (HBOC)-201, may alleviate the logistical constraints of using FWB in a prehospital setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB, whether conversion from SAAP to extracorporeal life support (ECLS) is feasible, and whether physiologic derangement post-SAAP therapy is reversible. METHODS Twenty-six swine (79 ± 4 kg) were anesthetized and underwent HiTCA which was induced via liver injury and controlled hemorrhage. Following arrest, swine were randomly allocated to resuscitation using SAAP with FWB (n = 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a 20-minute prehospital period prior to a 40-minute damage control surgery and resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included rate of ROSC, survival, conversion to ECLS, and correction of physiology. RESULTS Baseline physiologic measurements were similar between groups. ROSC was achieved in 100% of the FWB animals and 86% of the HBOC-201 animals (p = 0.483). Survival (t = 320 minutes) was 92% (11/12) in the FWB group and 67% (8/12) in the HBOC-201 group (p = 0.120). Conversion to ECLS was successful in 100% of both groups. Lactate peaked at 80 minutes in both groups, and significantly improved by the end of the experiment in the HBOC-201 group (p = 0.001) but not in the FWB group (p = 0.104). There was no significant difference in peak or end lactate between groups. CONCLUSION Selective aortic arch perfusion is effective in eliciting ROSC after HiTCA in a swine model, using either FWB or HBOC-201. Transition from SAAP to ECLS after definitive hemorrhage control is feasible, resulting in high overall survival and improvement in lactic acidosis over the study period.

Safety profile of high molecular weight polymerized hemoglobins

“…To better understand differences in the efficacy between T‐state and R‐state PolybHb, further studies in animals under pathological conditions are necessary, since high or low O 2 affinity might be beneficial depending on the type of pathological model used. Other HBOCs have been tested and show that HBOCs improve recovery from septic shock, hemorrhagic shock, and myocardial infarction 34–38 . The high viscosity of these materials may preclude their use in certain scenarios where the PolybHb comprises most of the blood (such as after significant hemorrhage), as patients may not tolerate the increased cardiac load, particularly when the heart is already compromised.…”

Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR) in Traumatic Cardiac Arrests Caused by Penetrating Thoracic Injuries: A Series of Two Cases

“…The underlying reason was also to increase postload if blunt cardiac injury (by shock waves) took place. Other bridging techniques for severely unstable or even arrested patients have been described in the literature, such as selective aortic arch perfusion [10] and different mechanical devices, e.g. Impella (Abiomed Inc., USA) and others, that can be more suitable options as a bridge to ECMO [11].…”

State‐of‐the‐art methods for the treatment of severe hemorrhagic trauma: selective aortic arch perfusion and emergency preservation and resuscitation—what is next?

“…In previous studies, the SAAP catheter acted as an arterial blood cannula and could be assisted with a flow rate of 500 mL/min. 28 Therefore, extracorporeal circulation support of SAAP using an oxygen carrier such as whole blood may restore the normal electrical activity of the heart and rapidly replenish circulation volume. This catheter can also be used as an intraaortic route for administration of epinephrine or drugs capable of alleviating ischemia-reperfusion injury.…”

“…29 After definitive hemorrhage control is established, the conversion to full-flow extracorporeal life support (ECLS) has been demonstrated to be feasible. 28 Barnard and colleagues described a liver lobectomy-induced HiTCA swine model. They classified transcatheter arterial hemorrhage into three groups to compare ROSC achievement rate and 60min survival rate: REBOA with fresh whole blood (FWB) intravenous administration (FWB-REBOA group), SAAP using oxygenated Ringer's solution (LR) (LR-SAAP group), and SAAP using oxygenated FWB (FWB-SAAP group).…”

“…25,26 Artificial hemoglobinbased oxygen carrier (HBOC) as SAAP perfusate achieved ROSC and short-term survival rates similar to FWB with similar physiological adverse effects. 28 Hoops further suggested it may be easier to administer in clinical settings. The only significant difference in physiological derangement between HBOC and FWB was pulmonary hypertension, a known short-term side effect of HBOC because of its vasoconstrictor and nitric oxide scavenging action, which was higher in the HBOC group, 28 and previous studies have shown that sodium nitrate might antagonize these actions.…”