小儿血流动力学悬崖是否存在于失血性休克反应中？

Does the pediatric hemodynamic cliff exist in response to hemorrhagic shock?

机构信息

Department of Surgery, University of California-Davis, Sacramento, CA; Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA.

Department of Surgery, University of California-Davis, Sacramento, CA.

出版信息

J Pediatr Surg. 2020 Dec;55(12):2543-2547. doi: 10.1016/j.jpedsurg.2020.08.003. Epub 2020 Aug 15.

DOI:10.1016/j.jpedsurg.2020.08.003

PMID:32900511

Abstract

BACKGROUND

The paradigm that children maintain normal blood pressure during hemorrhagic shock until 30%-45% hemorrhage is widely accepted. There are minimal data supporting when decompensation occurs and how a child's vasculature compensates up to that point. We aimed to observe the arterial response to hemorrhage and when mean arterial pressure (MAP) decreased from baseline in pediatric swine.

METHODS

Piglets were hemorrhaged in 20% increments of their total blood volume to 60%. MAP and angiograms of the thoracic aorta (TA) and abdominal arteries were obtained. Percent change in area of the vessels from baseline was calculated.

RESULTS

Piglets (n = 8) had a differential vasoconstriction starting at 20% hemorrhage (celiac artery 36.3% [31.4-44.6] vs TA 16.7% [10.7-19.1] p = 0.0012). At 40% hemorrhage, the differential vasoconstriction favored shunting blood away from the abdominal visceral branches to the TA (celiac artery 54.7% [36.9-60.6] vs TA 29.5% [23.9-36.2] p = 0.0056 superior mesenteric artery 46.7% [43.9-68.6] vs TA 29.5% [23.9-36.2] p = 0.0100). This was exacerbated at 60% hemorrhage. MAP decreased from baseline at 20% hemorrhage (66.4 ± 6.0 mmHg vs 41.4 ± 10.4 mmHg, p < 0.0001), and worsened at 40% and 60% hemorrhage.

CONCLUSION

In piglets, a differential vasocontriction shunting blood proximally occurred in response to hemorrhage. This did not maintain normal MAP at 20%, 40% or 60% hemorrhage.

LEVEL OF EVIDENCE

Level II.

摘要

背景

儿童在失血性休克期间维持正常血压直至失血 30%-45%的观点已被广泛接受。目前仅有很少的数据支持失代偿发生的时间以及儿童的脉管系统在此之前如何代偿。我们旨在观察小儿猪的动脉对出血的反应，以及平均动脉压（MAP）从基线下降的时间。

方法

将小猪以其总血量的 20%递增直至 60%进行出血。获得 MAP 和胸主动脉（TA）及腹部动脉的血管造影。从基线计算血管面积的百分比变化。

结果

小猪（n=8）在 20%出血时开始出现差异血管收缩（腹腔动脉 36.3%[31.4-44.6]与 TA 16.7%[10.7-19.1]，p=0.0012）。在 40%出血时，差异血管收缩有利于将血液从腹部内脏分支分流至 TA（腹腔动脉 54.7%[36.9-60.6]与 TA 29.5%[23.9-36.2]，p=0.0056；肠系膜上动脉 46.7%[43.9-68.6]与 TA 29.5%[23.9-36.2]，p=0.0100）。在 60%出血时更加明显。MAP 从基线在 20%出血时下降（66.4±6.0mmHg 与 41.4±10.4mmHg，p<0.0001），并在 40%和 60%出血时恶化。