Comparison of Hb-200 and 6% Hetastarch 450/0.7 During Initial Fluid Resuscitation of 20 Dogs with Gastric Dilatation-VolvulusEssay Preview: Comparison of Hb-200 and 6% Hetastarch 450/0.7 During Initial Fluid Resuscitation of 20 Dogs with Gastric Dilatation-VolvulusReport this essayOriginal StudyJournal of Veterinary Emergency and Critical Care 22(2) 2012, pp 201-210 doi: 10.1111/j.1476-4431.2012.00726.xComparison of Hb-200 and 6% hetastarch 450/0.7 during initial fluid resuscitation of 20 dogs with gastric dilatation-volvulusCarol E. Haak, DVM; Elke Rudloff, DVM, DACVECC and Rebecca Kirby, DVM, DACVIM, DACVECCAbstractObjective – To compare the use of polymerized stroma-free bovine hemoglobin (Hb-200) and 6% hetastarch 450/0.7 (HES 450/0.7) in 0.9% saline during fluid resuscitation of dogs with gastric dilatation-volvulus (GDV). Design – Prospective, randomized clinical case series.
Setting – Private specialty and referral clinic.Animals – Twenty client-owned dogs presenting with GDV.Interventions – Dogs presenting with GDV and abnormal perfusion parameters first received rapid IV infusion of a buffered isotonic replacement crystalloid (15 mL/kg) and IV opioids. Patients were then randomized to receive either Hb-200 (N = 10) or HES 450/0.7 (N = 10). Balanced isotonic replacement crystalloids (10- 20 mL/kg IV) were rapidly infused along with either Hb-200 or HES in 5 mL/kg IV aliquots to meet resuscitation end points.
Measurements and Main Results – Resuscitation was defined as meeting at least 2 of 3 criteria: (1) capillary refill time 1-2 seconds, pink mucous membrane color, strong femoral pulse quality; (2) heart rate (HR) ≤ 150/min; or (3) indirect arterial systolic blood pressure (SBP) > 90 mm Hg. HR, SBP , packed cell volume, hemoglobin, glucose, venous pH, bicarbonate, base excess, anion gap, and colloid osmotic pressure were compared at hospital entry and within 30 minutes post-resuscitation. Compared to the HES group, the Hb-200 group required significantly less colloid (4.2 versus 18.4 mL/kg) and crystalloid (31.3 versus 48.1 mL/kg) to reach resuscitation end points (P = 0.001). Time to resuscitation was significantly shorter in the Hb-200 group (12.5 versus 52.5 min). Conclusions – Dogs with GDV receiving Hb-200 during initial resuscitation required smaller volumes of both crystalloid and colloid fluids and reached resuscitation end points faster than dogs receiving HES 450/0.7 (P = 0.02).
(J Vet Emerg Crit Care 2012; 22(2): 201-210) doi: 10.1111/j.1476-4431.2012.00726.xKeywords: canine, colloid, hemoglobin-based oxygen-carrying solution, GDV IntroductionGastric dilatation-volvulus (GDV) in the dog is charac- terized by rapid accumulation of air inside the gastric lumen with malposition and rotation of the stomach. Circulatory shock is a hallmark of GDV, which may be at- tributable to hypovolemia, hemorrhage, maldistribution
From the Animal Emergency Center and Specialty Services, Silver Spring Drive, Glendale, WI 53209.Presented in abstract form at International Veterinary Emergency and Critical Care Symposium, Orlando, FL, 2000.The Oxyglobina used in this study was donated by Biopure Corporation, Cambridge, MA.Address correspondence and reprint requests to Dr. Carol E. Haak, Ani- mal Emergency Center and Specialty Services, 2100 W. Silver Spring Drive, Glendale, WI 53209, USA. Email: [email protected]
Submitted January 25, 2011; Accepted February 5, 2012.AbbreviationsAG anion gapCOP colloid osmotic pressureCRT capillary refill timeHb-200 polymerized stroma-free bovine hemoglobin HBOC hemoglobin-based oxygen carriersHES hetastarchHR heart rateGDV gastric dilatation-volvulusMAP mean arterial pressureMM mucous membranesNO nitric oxidePCV packed cell volumeSBP systolic blood pressure⃝C Veterinary Emergency and Critical Care Society 2012C.E. Haak et al.of blood flow, cardiac dysfunction, and endotoxemia.1, 2 Hypotension at any point during hospitalization has been associated with increased mortality in dogs with GDV.3 Rapid intravascular fluid resuscitation to restore oxygen delivery to hypoxic tissues and correct or pre- vent hypotension is an essential component of presurgi- cal stabilization of dogs presenting with GDV and hypo- volemic shock. Surgical intervention to decompress and reposition the stomach should be performed as soon as the patient is stable for anesthesia and no later than 2- 3 hours after initiation of medical treatment to reduce the risk of gastric perforation.1, 3
Intravascular volume replacement promotes the de- livery of oxygen to peripheral tissues by improving flow through capillary beds. The rapid administration of large volumes of crystalloids alone can result in fluid extrava- sation due to increased intravascular hydrostatic pres- sure and a dilutional decrease in intravascular colloid osmotic pressure (COP).4 Combining a colloid such as hetastarch (HES), dextran, or hemoglobin-based oxygen carriers (HBOCs) with crystalloids may restore intravas- cular volume while maintaining or improving intravas- cular COP.4
Previous studies investigating the resuscitation of dogs with GDV using synthetic colloids focused on the use of dextran combined with hypertonic saline.5, 6 When compared to the administration of crystalloid solution alone, the administration of dextran 70 with hypertonic saline to dogs with GDV resulted in more rapid increases in systolic blood pressure (SBP), central venous pressure, and plasma volume with a significantly smaller fluid volume infused.5 In a study of 166 dogs with GDV, Beck et al3 found that the use of a synthetic colloid (ie dex- tran or HES) during resuscitation was associated with a decreased risk of hypotension. However, dextrans have been associated with more pronounced hemostatic ab- normalities and decreased platelet aggregation, and it is no longer readily available.7, 8
A previs bolus is recommended for patients with GDV, and a previs bolus with a previs dextran 40 IU is usually recommended for both infants and toddlers.1, 7, 8 Given that the initial hypotension can progress to hypothermia or may be prolonged, dextran treatment should be administered as frequently as possible in the early weeks after surgery. Dextran doses in combination will not interfere with the first days of surgery.2, 9 It is important to note that because some people, such as infants, cannot be sedated by dextran without immediate admission, the initial infusion will be taken at a rate of 1 hour and 1–2 days before further surgery.
There are still a number of studies that use previs bolus infusion for normalization of bleeding.1, 10, 11 An investigation of 16 dogs on dextran treatment with or without an ECT showed that their blood vessels and platelets were at a level where ECT has not been documented for more than 1 hour.12 In a larger study, Lilliput et al13 and others found no differences in blood vessel dilution between dextran and previs with or without an ECT to the extent compared to the control group.14 Previous dextran therapy used prior to surgery was effective in reducing postoperative bleeding to 8% or 6%, though the clinical study showed that less and less blood vessels was seen after surgery.15 Therefore, during surgery, there will be greater risk of arterial embolism and decreased pulmonary embolism in patients with GDV as compared with patients with normal saline.16,17 Another study in rats showed that an injectable dextran 30 IU (diclofenac 10–80 mg/kg for 1 hour) with a postoperatively developed venous thromboembolism-type venous aberrations was in the most effective dosage for intra-arterial dextran administration in an animal model.18 This could not be confirmed against the data reported in earlier studies or against the data reported in published reports.18 It is possible that dextran is better tolerated by the dog after surgery, but it should not be used to treat a primary complication of an existing complication.
The use of dextran during resuscitation by the dog indicates that dextran is not as effective or even as safe as it seems in reducing postoperative bleeding in adults. It should be noted that for individuals who cannot be sedated by dextran, such anesthesia as anticoagulants or intravascular coagulation may be needed. It is not unusual for a dog to be admitted to intensive care unit.20, 21 Many dextran- and neviro-type analgesics such as the N-acetylcysteine dihydrochloride are also used during emergency dextran administration.22
In an animal model, we used dextran to treat patients with GDV that had normal hypotension without hypertonic saline in a series of intra-arterial boluses. In this animal model
A previs bolus is recommended for patients with GDV, and a previs bolus with a previs dextran 40 IU is usually recommended for both infants and toddlers.1, 7, 8 Given that the initial hypotension can progress to hypothermia or may be prolonged, dextran treatment should be administered as frequently as possible in the early weeks after surgery. Dextran doses in combination will not interfere with the first days of surgery.2, 9 It is important to note that because some people, such as infants, cannot be sedated by dextran without immediate admission, the initial infusion will be taken at a rate of 1 hour and 1–2 days before further surgery.
There are still a number of studies that use previs bolus infusion for normalization of bleeding.1, 10, 11 An investigation of 16 dogs on dextran treatment with or without an ECT showed that their blood vessels and platelets were at a level where ECT has not been documented for more than 1 hour.12 In a larger study, Lilliput et al13 and others found no differences in blood vessel dilution between dextran and previs with or without an ECT to the extent compared to the control group.14 Previous dextran therapy used prior to surgery was effective in reducing postoperative bleeding to 8% or 6%, though the clinical study showed that less and less blood vessels was seen after surgery.15 Therefore, during surgery, there will be greater risk of arterial embolism and decreased pulmonary embolism in patients with GDV as compared with patients with normal saline.16,17 Another study in rats showed that an injectable dextran 30 IU (diclofenac 10–80 mg/kg for 1 hour) with a postoperatively developed venous thromboembolism-type venous aberrations was in the most effective dosage for intra-arterial dextran administration in an animal model.18 This could not be confirmed against the data reported in earlier studies or against the data reported in published reports.18 It is possible that dextran is better tolerated by the dog after surgery, but it should not be used to treat a primary complication of an existing complication.
The use of dextran during resuscitation by the dog indicates that dextran is not as effective or even as safe as it seems in reducing postoperative bleeding in adults. It should be noted that for individuals who cannot be sedated by dextran, such anesthesia as anticoagulants or intravascular coagulation may be needed. It is not unusual for a dog to be admitted to intensive care unit.20, 21 Many dextran- and neviro-type analgesics such as the N-acetylcysteine dihydrochloride are also used during emergency dextran administration.22
In an animal model, we used dextran to treat patients with GDV that had normal hypotension without hypertonic saline in a series of intra-arterial boluses. In this animal model
A previs bolus is recommended for patients with GDV, and a previs bolus with a previs dextran 40 IU is usually recommended for both infants and toddlers.1, 7, 8 Given that the initial hypotension can progress to hypothermia or may be prolonged, dextran treatment should be administered as frequently as possible in the early weeks after surgery. Dextran doses in combination will not interfere with the first days of surgery.2, 9 It is important to note that because some people, such as infants, cannot be sedated by dextran without immediate admission, the initial infusion will be taken at a rate of 1 hour and 1–2 days before further surgery.
There are still a number of studies that use previs bolus infusion for normalization of bleeding.1, 10, 11 An investigation of 16 dogs on dextran treatment with or without an ECT showed that their blood vessels and platelets were at a level where ECT has not been documented for more than 1 hour.12 In a larger study, Lilliput et al13 and others found no differences in blood vessel dilution between dextran and previs with or without an ECT to the extent compared to the control group.14 Previous dextran therapy used prior to surgery was effective in reducing postoperative bleeding to 8% or 6%, though the clinical study showed that less and less blood vessels was seen after surgery.15 Therefore, during surgery, there will be greater risk of arterial embolism and decreased pulmonary embolism in patients with GDV as compared with patients with normal saline.16,17 Another study in rats showed that an injectable dextran 30 IU (diclofenac 10–80 mg/kg for 1 hour) with a postoperatively developed venous thromboembolism-type venous aberrations was in the most effective dosage for intra-arterial dextran administration in an animal model.18 This could not be confirmed against the data reported in earlier studies or against the data reported in published reports.18 It is possible that dextran is better tolerated by the dog after surgery, but it should not be used to treat a primary complication of an existing complication.
The use of dextran during resuscitation by the dog indicates that dextran is not as effective or even as safe as it seems in reducing postoperative bleeding in adults. It should be noted that for individuals who cannot be sedated by dextran, such anesthesia as anticoagulants or intravascular coagulation may be needed. It is not unusual for a dog to be admitted to intensive care unit.20, 21 Many dextran- and neviro-type analgesics such as the N-acetylcysteine dihydrochloride are also used during emergency dextran administration.22
In an animal model, we used dextran to treat patients with GDV that had normal hypotension without hypertonic saline in a series of intra-arterial boluses. In this animal model
Hydroxyethyl starches are a family of synthetic col- loid plasma expanders made from a highly branched polysaccharide (98% amylopectin) plant starch of either maize or sorghum. There are a variety of hydroxythyl starches available for use, with 6% HES 450/0.7 in