University of Cincinnati, Department of Surgery, 231 Albert Sabin Way (ML 0558), Cincinnati, OH 45267-0558.
Mil Med. 2020 Sep 18;185(9-10):e1528-e1535. doi: 10.1093/milmed/usz430.
Combined burn injury and hemorrhagic shock are a common cause of injury in wounded warfighters. Current protocols for resuscitation for isolated burn injury and isolated hemorrhagic shock are well defined, but the optimal strategy for combined injury is not fully established. Direct peritoneal resuscitation (DPR) has been shown to improve survival in rats after hemorrhagic shock, but its role in a combined burn/hemorrhage injury is unknown. We hypothesized that DPR would improve survival in mice subjected to combined burn injury and hemorrhage.
Male C57/BL6J mice aged 8 weeks were subjected to a 7-second 30% total body surface area scald in a 90°C water bath. Following the scald, mice received DPR with 1.5 mL normal saline or 1.5 mL peritoneal dialysis solution (Delflex). Control mice received no peritoneal solution. Mice underwent a controlled hemorrhage shock via femoral artery cannulation to a systolic blood pressure of 25 mm Hg for 30 minutes. Mice were then resuscitated to a target blood pressure with either lactated Ringer's (LR) or a 1:1 ratio of packed red blood cells (pRBCs) and fresh frozen plasma (FFP). Mice were observed for 24 hours following injury.
Median survival time for mice with no DPR was 1.47 hours in combination with intravascular LR resuscitation and 2.08 hours with 1:1 pRBC:FFP. Median survival time significantly improved with the addition of intraperitoneal normal saline or Delflex. Mice that received DPR followed by 1:1 pRBC:FFP required less intravascular volume than mice that received DPR with LR, pRBC:FFP alone, and LR alone. Intraperitoneal Delflex was associated with higher levels of tumor necrosis factor alpha and macrophage inflammatory protein 1 alpha and lower levels of interleukin 10 and intestinal fatty acid binding protein. Intraperitoneal normal saline resulted in less lung injury 1 hour postresuscitation, but increased to similar severity of Delflex at 4 hours.
After a combined burn injury and hemorrhage, DPR leads to increased survival in mice. Survival was similar with the use of normal saline or Delflex. DPR with normal saline reduced the inflammatory response seen with Delflex and delayed the progression of acute lung injury. DPR may be a valuable strategy in the treatment of patients with combined burn injury and hemorrhage.
联合烧伤和失血性休克是战伤伤员常见的损伤原因。目前对于孤立性烧伤损伤和孤立性失血性休克的复苏方案已有明确规定，但联合损伤的最佳策略尚未完全确定。腹膜直接复苏（DPR）已被证明可提高失血性休克大鼠的存活率，但它在联合烧伤/失血性损伤中的作用尚不清楚。我们假设 DPR 可提高合并烧伤和出血的小鼠的存活率。
8 周龄雄性 C57/BL6J 小鼠接受 90°C 水浴中 7 秒 30%全身体表面积烫伤。烫伤后，用 1.5mL 生理盐水或 1.5mL 腹膜透析液（Delflex）进行 DPR。对照组小鼠未给予腹膜溶液。通过股动脉插管将小鼠控制至收缩压 25mmHg，以进行 30 分钟的失血性休克。然后，用乳酸林格氏液（LR）或浓缩红细胞（pRBC）与新鲜冷冻血浆（FFP）的 1:1 比例将小鼠复苏至目标血压。受伤后观察 24 小时。
未进行 DPR 的小鼠，在接受静脉内 LR 复苏的情况下，中位生存时间为 1.47 小时，在接受 1:1 pRBC:FFP 的情况下，中位生存时间为 2.08 小时。用腹腔内生理盐水或 Delflex 进行 DPR 后，中位生存时间显著延长。接受 DPR 后再给予 1:1 pRBC:FFP 的小鼠所需的血管内容量低于单独给予 DPR 与 LR、单独给予 pRBC:FFP 与 LR 的小鼠。腹腔内 Delflex 与较高水平的肿瘤坏死因子-α和巨噬细胞炎症蛋白 1α以及较低水平的白细胞介素 10 和肠脂肪酸结合蛋白相关。腹腔内生理盐水在复苏后 1 小时可减轻肺损伤，但在 4 小时时其严重程度与 Delflex 相似。
在联合烧伤和出血后，DPR 可提高小鼠的存活率。使用生理盐水或 Delflex 的效果相似。用生理盐水进行 DPR 可减少 Delflex 引起的炎症反应，并延迟急性肺损伤的进展。DPR 可能是治疗合并烧伤和出血的患者的一种有价值的策略。
