Page 56 - JSOM Fall 2023

FIGURE 2 Hemodynamics and metabolic resuscitation. (A) Average FIGURE 3 Intracranial pressure and cerebral perfusion pressure.
mean arterial pressure (MAP), (B) cardiac output measured by ICP was increased overall during resuscitation with infusion, averaging
thermodilution, and (C) arterial lactate concentration for bolus and 10.6mmHg compared with bolus at 5.9mmHg (RM ANOVA
infusion groups plotted over time. treatment group, p < .001). However, there were no individual
differences during resuscitation (RM ANOVA interaction, p = .26).
Mean CPP was als o significantly increased overall during resuscitation
at 36.4mmHg with infusion versus 31.3mmHg with bolus treatment
(RM ANOVA treatment group, p = .015). Again, there were no
individual differences at specific time points measured for CPP
(RM ANOVA treatment group*protocol time interaction, p = .43).

CPP, cranial perfusion pressure; ICP, intracranial perfusion pressure;
RM ANOVA, repeated measures analysis of variance
Error bars = 95% confidence interval

It is notable that the blood pressure within the bolus group was
increased only with the first bolus compared with infusion,
suggesting that early increased blood loss induced an inabil-
ity to recover hemodynamics during subsequent fluid boluses
later during resuscitation. Similar results were seen in a previ-
ous porcine NCTH model reported by Stern et al using 7.5%
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*Indicates significant individual difference vs bolus group at desig- NaCl/6% dextran-70 (dextran-70, Rugby Laboratories, Li-
®
nated time after Tukey adjustment for multiple comparisons. vonia, MI). The authors found that infusing the resuscitation
Error bars = 95% confidence interval.
fluid at one-third the control rate improved 90-minute sur-
vival and decreased intraperitoneal blood loss. Systemic blood
pressure during the first DCR cocktail bolus is the likely culprit pressure was increased during the first 15 minutes of resuscita-
that increased internal blood loss in the bolus group, despite in- tion in the faster infusion group. These results point toward
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ducing overall lower blood pressure during the first 60 minutes. the first 10 to 15 minutes of fluid resuscitation of NCTH as
being a critical time that should be managed very carefully to
Discussion avoid inducing rebleeding events. Therefore, a more measured
approach to fluid resuscitation of NCTH, given more slowly
The primary result of this study is that slow infusion of the and over longer periods of time, may more readily achieve the
DCR cocktail decreased internal hemorrhage compared with goal of providing limited resuscitation without encouraging
bolus administration in a swine model of polytrauma with TBI rebleeding.
and NCTH. We attribute the increased hemorrhage volume
with the bolus group to early increased systemic blood pres- Limited or delayed resuscitation of hemorrhagic shock is not
sure during the first bolus. Alternative explanations, including a new concept and is a core tenant of damage control resusci-
differences in overall fluid infusion volumes, initial blood loss, tation, where the primary intent is to preserve life rather than
or clot formation, do not appear to apply because they were provide full physiologic resuscitation. Limiting fluid resus-
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similar between groups. In addition, slow infusion of the DCR citation has been operationalized with good effect in several
cocktail provided improved hemodynamic, metabolic, and ce- different ways in clinical trials, including limiting the volume
rebral resuscitation parameters without negatively affecting of resuscitation fluids given, decreasing goal blood-pressure
vital organ perfusion. targets, and delaying the onset of fluid resuscitation. 18–20 Our

54 | JSOM Volume 22, Edition 3 / Fall 2023