Fresh Whole Blood resuscitation does not exacerbate skeletal muscle edema and long-term functional deficit after ischemic injury and hemorrhagic shock

ABSTRACTBACKGROUNDHemorrhagic shock due to extremity vascular injuries is common in combat injuries. Fluid resuscitation is the standard treatment for severe hemorrhage. Tourniquets (TK) used for hemorrhage control cause ischemia-reperfusion (I/R) injury that induces edema formation in the injured muscle. Resuscitation fluids affect edema formation; however, its effect on long-term functional response remains unknown. The objectives of this study are 1) compare acute muscle damage; 2) determine long-term functional recovery of ischemic muscle, and 3) compare local and systemic inflammatory response including the expression of junctional proteins following early resuscitation with HextendTM (HEX) and Fresh Whole Blood (FWB) using a rodent model of combined hemorrhage and TK-induced limb I/R.METHODSAnesthetized Sprague-Dawley rats underwent 42.5% arterial hemorrhage, followed by 3 hours of TK application. Animals were either not resuscitated or resuscitated with HEX or FWB. Two time points were evaluated, 2 and 28 days. Plasma cytokine concentrations were determined at baseline and end resuscitation. At two days, edema formation, expression of junctional proteins, and tissue level cytokines concentrations were evaluated. At 28 days, in vivo muscle contractile properties were determined. At both time-points, routine histology was performed and graded using a semi-quantitative grading system.RESULTSAll animals developed hemorrhagic hypovolemia; the mortality rate was 100% in non-resuscitated rats. HEX resuscitation exacerbated muscle edema (~11%) and muscle strength deficit (~20%). FWB resuscitation presented edema and muscle strength akin to TK only. FWB resuscitation pup-regulated expression of junctional proteins including pro-angiogenic factors and dampened the inflammatory response.CONCLUSIONFWB resuscitation does not exacerbate either TK induced edema or muscle strength deficit. FWB resuscitation may reduce both acute and long-term morbidity associated with extremity trauma. To our knowledge, this is the first study to demonstrate the nature of the resuscitation fluid administered following hemorrhage impacts short- and long-term indices of I/R in skeletal muscle.LEVEL OF EVIDENCEN/A BACKGROUND Hemorrhagic shock due to extremity vascular injuries is common in combat injuries. Fluid resuscitation is the standard treatment for severe hemorrhage. Tourniquets (TK) used for hemorrhage control cause ischemia-reperfusion (I/R) injury that induces edema formation in the injured muscle. Resuscitation fluids affect edema formation; however, its effect on long-term functional response remains unknown. The objectives of this study are 1) compare acute muscle damage; 2) determine long-term functional recovery of ischemic muscle, and 3) compare local and systemic inflammatory response including the expression of junctional proteins following early resuscitation with HextendTM (HEX) and Fresh Whole Blood (FWB) using a rodent model of combined hemorrhage and TK-induced limb I/R. METHODS Anesthetized Sprague-Dawley rats underwent 42.5% arterial hemorrhage, followed by 3 hours of TK application. Animals were either not resuscitated or resuscitated with HEX or FWB. Two time points were evaluated, 2 and 28 days. Plasma cytokine concentrations were determined at baseline and end resuscitation. At two days, edema formation, expression of junctional proteins, and tissue level cytokines concentrations were evaluated. At 28 days, in vivo muscle contractile properties were determined. At both time-points, routine histology was performed and graded using a semi-quantitative grading system. RESULTS All animals developed hemorrhagic hypovolemia; the mortality rate was 100% in non-resuscitated rats. HEX resuscitation exacerbated muscle edema (~11%) and muscle strength deficit (~20%). FWB resuscitation presented edema and muscle strength akin to TK only. FWB resuscitation pup-regulated expression of junctional proteins including pro-angiogenic factors and dampened the inflammatory response. CONCLUSION FWB resuscitation does not exacerbate either TK induced edema or muscle strength deficit. FWB resuscitation may reduce both acute and long-term morbidity associated with extremity trauma. To our knowledge, this is the first study to demonstrate the nature of the resuscitation fluid administered following hemorrhage impacts short- and long-term indices of I/R in skeletal muscle. LEVEL OF EVIDENCE N/A *Corresponding Author: Thomas Walters, PhD, Extremity Trauma and Regenerative Medicine, Institute of Surgical Research, 3698 Chambers Pass, JBSA Ft Sam Houston, TX 78234-7767, United States of America, Telephone: (210)-539-2726; Fax: (210)-539-3877. E-mail: thomas.j.walters22.civ@mail.mil There are no conflicts of interest This work was funded by the Combat Casualty Care Research Program, U.S. Army Medical Research and Materiel Command. “The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.” © 2018 Lippincott Williams & Wilkins, Inc.

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