Endovascular Perfusion Augmentation for Critical Care

Partial Aortic Occlusion for Treatment of Severe Ischemia-Reperfusion Shock

Michael Johnson, Emily M. Tibbits, Guillaume L. Hoareau, Meryl A. Simon, Anders J. Davidson, Erik S. DeSoucy, E. Robert Faulconer, J. Kevin Grayson, Lucas P. Neff, Timothy K. Williams

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

BACKGROUND: The resuscitation of patients in shock is materially intensive and many patients are refractory to maximal therapy. We hypothesized that partial inflation of an intra-aortic balloon, termed Endovascular Perfusion Augmentation for Critical Care (EPACC), would minimize material requirements while improving physiologic metrics. METHODS: Swine underwent a 25% controlled bleed and 45 min of complete aortic occlusion to create a severe ischemia-reperfusion shock state. Animals received either standardized critical care (SCC) composed of IV fluids and norepinephrine delivered through an algorithmically controlled platform or EPACC in addition to SCC. Physiologic parameters were collected, and blood was sampled for analysis. Primary outcomes were total IV fluids and average MAP during the critical care phase. Differences (P < 0.05) were measured with t test (continuous data) and Wilcoxon rank-sum test (ordinal data). RESULTS: There were no differences in baseline characteristics. There were no differences in the maximum lactate; however, animals in the EPACC group had a higher average MAP (EPACC 65 mmHg, 95% confidence interval [CI], 65-66; SCC 60 mmHg, 95% CI, 57-63; P < 0.01) and remained within goal MAP for a greater period of time (EPACC 95.3%, 95% CI, 93.2-97.4; SCC 51.0%, 95% CI, 29.5-72.6; P < 0.01). EPACC animals required less IV fluids when compared with the SCC group (EPACC 21 mL/kg, 95% CI, 0-42; SCC 96 mL/kg, 95% CI, 76-117; P < 0.01). There were no differences in final lactate. Animals in the EPACC group had a higher final creatinine (EPACC 2.3 mg/dL, 95% CI, 2.1-2.5; SCC 1.7 mg/dL, 95% CI, 1.4-2.0; P < 0.01), but there were no differences in renal cellular damage on histology (P = 0.16). CONCLUSION: Using a swine model of severe shock, the addition of EPACC to SCC significantly reduced fluid resuscitation requirements and improved blood pressure. This is the first description of a new therapy for patients in refractory shock or in resource-limited settings.

Original languageEnglish (US)
Pages (from-to)659-666
Number of pages8
JournalShock (Augusta, Ga.)
Volume51
Issue number5
DOIs
StatePublished - May 1 2019

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Critical Care
Reperfusion
Shock
Ischemia
Perfusion
Confidence Intervals
Therapeutics
Nonparametric Statistics
Resuscitation
Lactic Acid
Swine
Economic Inflation

ASJC Scopus subject areas

  • Emergency Medicine
  • Critical Care and Intensive Care Medicine

Cite this

Endovascular Perfusion Augmentation for Critical Care : Partial Aortic Occlusion for Treatment of Severe Ischemia-Reperfusion Shock. / Johnson, Michael; Tibbits, Emily M.; Hoareau, Guillaume L.; Simon, Meryl A.; Davidson, Anders J.; DeSoucy, Erik S.; Faulconer, E. Robert; Grayson, J. Kevin; Neff, Lucas P.; Williams, Timothy K.

In: Shock (Augusta, Ga.), Vol. 51, No. 5, 01.05.2019, p. 659-666.

Research output: Contribution to journalArticle

Johnson, M, Tibbits, EM, Hoareau, GL, Simon, MA, Davidson, AJ, DeSoucy, ES, Faulconer, ER, Grayson, JK, Neff, LP & Williams, TK 2019, 'Endovascular Perfusion Augmentation for Critical Care: Partial Aortic Occlusion for Treatment of Severe Ischemia-Reperfusion Shock', Shock (Augusta, Ga.), vol. 51, no. 5, pp. 659-666. https://doi.org/10.1097/SHK.0000000000001199
Johnson, Michael ; Tibbits, Emily M. ; Hoareau, Guillaume L. ; Simon, Meryl A. ; Davidson, Anders J. ; DeSoucy, Erik S. ; Faulconer, E. Robert ; Grayson, J. Kevin ; Neff, Lucas P. ; Williams, Timothy K. / Endovascular Perfusion Augmentation for Critical Care : Partial Aortic Occlusion for Treatment of Severe Ischemia-Reperfusion Shock. In: Shock (Augusta, Ga.). 2019 ; Vol. 51, No. 5. pp. 659-666.
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abstract = "BACKGROUND: The resuscitation of patients in shock is materially intensive and many patients are refractory to maximal therapy. We hypothesized that partial inflation of an intra-aortic balloon, termed Endovascular Perfusion Augmentation for Critical Care (EPACC), would minimize material requirements while improving physiologic metrics. METHODS: Swine underwent a 25{\%} controlled bleed and 45 min of complete aortic occlusion to create a severe ischemia-reperfusion shock state. Animals received either standardized critical care (SCC) composed of IV fluids and norepinephrine delivered through an algorithmically controlled platform or EPACC in addition to SCC. Physiologic parameters were collected, and blood was sampled for analysis. Primary outcomes were total IV fluids and average MAP during the critical care phase. Differences (P < 0.05) were measured with t test (continuous data) and Wilcoxon rank-sum test (ordinal data). RESULTS: There were no differences in baseline characteristics. There were no differences in the maximum lactate; however, animals in the EPACC group had a higher average MAP (EPACC 65 mmHg, 95{\%} confidence interval [CI], 65-66; SCC 60 mmHg, 95{\%} CI, 57-63; P < 0.01) and remained within goal MAP for a greater period of time (EPACC 95.3{\%}, 95{\%} CI, 93.2-97.4; SCC 51.0{\%}, 95{\%} CI, 29.5-72.6; P < 0.01). EPACC animals required less IV fluids when compared with the SCC group (EPACC 21 mL/kg, 95{\%} CI, 0-42; SCC 96 mL/kg, 95{\%} CI, 76-117; P < 0.01). There were no differences in final lactate. Animals in the EPACC group had a higher final creatinine (EPACC 2.3 mg/dL, 95{\%} CI, 2.1-2.5; SCC 1.7 mg/dL, 95{\%} CI, 1.4-2.0; P < 0.01), but there were no differences in renal cellular damage on histology (P = 0.16). CONCLUSION: Using a swine model of severe shock, the addition of EPACC to SCC significantly reduced fluid resuscitation requirements and improved blood pressure. This is the first description of a new therapy for patients in refractory shock or in resource-limited settings.",
author = "Michael Johnson and Tibbits, {Emily M.} and Hoareau, {Guillaume L.} and Simon, {Meryl A.} and Davidson, {Anders J.} and DeSoucy, {Erik S.} and Faulconer, {E. Robert} and Grayson, {J. Kevin} and Neff, {Lucas P.} and Williams, {Timothy K.}",
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T2 - Partial Aortic Occlusion for Treatment of Severe Ischemia-Reperfusion Shock

AU - Johnson, Michael

AU - Tibbits, Emily M.

AU - Hoareau, Guillaume L.

AU - Simon, Meryl A.

AU - Davidson, Anders J.

AU - DeSoucy, Erik S.

AU - Faulconer, E. Robert

AU - Grayson, J. Kevin

AU - Neff, Lucas P.

AU - Williams, Timothy K.

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N2 - BACKGROUND: The resuscitation of patients in shock is materially intensive and many patients are refractory to maximal therapy. We hypothesized that partial inflation of an intra-aortic balloon, termed Endovascular Perfusion Augmentation for Critical Care (EPACC), would minimize material requirements while improving physiologic metrics. METHODS: Swine underwent a 25% controlled bleed and 45 min of complete aortic occlusion to create a severe ischemia-reperfusion shock state. Animals received either standardized critical care (SCC) composed of IV fluids and norepinephrine delivered through an algorithmically controlled platform or EPACC in addition to SCC. Physiologic parameters were collected, and blood was sampled for analysis. Primary outcomes were total IV fluids and average MAP during the critical care phase. Differences (P < 0.05) were measured with t test (continuous data) and Wilcoxon rank-sum test (ordinal data). RESULTS: There were no differences in baseline characteristics. There were no differences in the maximum lactate; however, animals in the EPACC group had a higher average MAP (EPACC 65 mmHg, 95% confidence interval [CI], 65-66; SCC 60 mmHg, 95% CI, 57-63; P < 0.01) and remained within goal MAP for a greater period of time (EPACC 95.3%, 95% CI, 93.2-97.4; SCC 51.0%, 95% CI, 29.5-72.6; P < 0.01). EPACC animals required less IV fluids when compared with the SCC group (EPACC 21 mL/kg, 95% CI, 0-42; SCC 96 mL/kg, 95% CI, 76-117; P < 0.01). There were no differences in final lactate. Animals in the EPACC group had a higher final creatinine (EPACC 2.3 mg/dL, 95% CI, 2.1-2.5; SCC 1.7 mg/dL, 95% CI, 1.4-2.0; P < 0.01), but there were no differences in renal cellular damage on histology (P = 0.16). CONCLUSION: Using a swine model of severe shock, the addition of EPACC to SCC significantly reduced fluid resuscitation requirements and improved blood pressure. This is the first description of a new therapy for patients in refractory shock or in resource-limited settings.

AB - BACKGROUND: The resuscitation of patients in shock is materially intensive and many patients are refractory to maximal therapy. We hypothesized that partial inflation of an intra-aortic balloon, termed Endovascular Perfusion Augmentation for Critical Care (EPACC), would minimize material requirements while improving physiologic metrics. METHODS: Swine underwent a 25% controlled bleed and 45 min of complete aortic occlusion to create a severe ischemia-reperfusion shock state. Animals received either standardized critical care (SCC) composed of IV fluids and norepinephrine delivered through an algorithmically controlled platform or EPACC in addition to SCC. Physiologic parameters were collected, and blood was sampled for analysis. Primary outcomes were total IV fluids and average MAP during the critical care phase. Differences (P < 0.05) were measured with t test (continuous data) and Wilcoxon rank-sum test (ordinal data). RESULTS: There were no differences in baseline characteristics. There were no differences in the maximum lactate; however, animals in the EPACC group had a higher average MAP (EPACC 65 mmHg, 95% confidence interval [CI], 65-66; SCC 60 mmHg, 95% CI, 57-63; P < 0.01) and remained within goal MAP for a greater period of time (EPACC 95.3%, 95% CI, 93.2-97.4; SCC 51.0%, 95% CI, 29.5-72.6; P < 0.01). EPACC animals required less IV fluids when compared with the SCC group (EPACC 21 mL/kg, 95% CI, 0-42; SCC 96 mL/kg, 95% CI, 76-117; P < 0.01). There were no differences in final lactate. Animals in the EPACC group had a higher final creatinine (EPACC 2.3 mg/dL, 95% CI, 2.1-2.5; SCC 1.7 mg/dL, 95% CI, 1.4-2.0; P < 0.01), but there were no differences in renal cellular damage on histology (P = 0.16). CONCLUSION: Using a swine model of severe shock, the addition of EPACC to SCC significantly reduced fluid resuscitation requirements and improved blood pressure. This is the first description of a new therapy for patients in refractory shock or in resource-limited settings.

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