CC BY
51
Pancreatoprotection of Malate-Containing
Infusion Solutions in Experimental
Hemorrhagic Sh ock
UDC 616.001.6–005.1–001.36:616.37–002
Received 2.05.012
А.Y. Yakovlev, D.Med.Sc., Associate Professor, curator of the Intensive Care Unit1;
L.B. Snopova, D.Bio.Sc., Associate Professor, Head of the Morphology Department,
Central Scientific Research Laboratory of Scientific Research Institute of Applied and Fundamental Medicine2;
Т.А. Galanina, Head of the Intensive Care Unit, Nizhny Novgorod Regional Traumatology Centre1;
D.V. Ryabikov, Traumatologist1;
D.М. Protasov, Emergency Physician1
1N.A. Semashko Nizhny Novgorod Regional Clinical Hospital, Rodionova St., 190, Nizhny Novgorod,
Russian Federation, 603126;
2Nizhny Novgorod State Medical Academy, Minin and Pozharsky Square, 10/1, Nizhny Novgorod,
Russian Federation, 603005
The aim of the investigation was to study in experiment the effect of Sterofundin isotonic on the development of post-hemorrhagic damage
of the pancreas.
Materials and Methods. The experiments were carried out on 36 male Wistar rats weighing 230–250 g. Hemorrhagic shock was stimulated
by acute massive hemorrhage to the extent of 2.5 mL/100 g at rate of 2 mL/min. The blood loss an hour later was followed by the replacement of
hypovolemia within 60 min by 200% of the lost volume: in control group — by Ringer’s solution, in test group — by Sterofundin isotonic. Then
there was performed reinfusion in the volume of 70% of blood loss. On day 1 and 3 after hemorrhagic shock we assessed the laboratory findings
and morphological changes of the pancreas.
Results. There was found pancreatoprotective action of isotonic Sterofundin, a malate-containing blood substitute in infusion therapy of
experimental hemorrhagic shock.
Key words: hemorrhagic shock; malate; Sterofundin isotonic; pancreas.
Since constantly high level of mortality associated with the development of posthemorrhagic polyorgan failure the active search of critical care measures contributing the improvement of adaptiveness of inner organs to ischemia and following reperfusion [1-4]. The pancreas is one of target organs for this injury mechanism as it is always in severe shock being off from the circulation due to its centralization. The subsequent development of acute pancreatitis, especially its destructive forms, significantly increases the risk of death [5]. It determines the development of new directions in therapy [6]. In the arsenal of modern blood replacement in recent years, the products containing substrate antihypoxants appeared, but their effect on hemorrhagic damage to the pancreas is unstudied. Fumarate is added as a substrate antihypoxants in blood substitutes (Mafusol), succinate (Reamberin and Remaxol) and malate (Sterofundin isotonic and Sterofundin D-5).
Sterofundin isotonic is norme osmolar balanced polyion solution that can be safely administered by bolus in critical conditions involving hypovolemia and it determined the selection of the study drug.
The aim of the investigation was to study in experiment
the effect of Sterofundin isotonic on the development of post-hemorrhagic damage of the pancreas.
Materials and Methods. Experiments were conducted on 36 male rats of Wistar line, weighing 230-250 g. The research was performed according to the ethical principles established by the European Convention for the protection of vertebrata used for experimental and other scientific purposes (adopted in Strasbourg, Mar, 18, 1986, and confirmed in Strasbourg Jun, 15, 2006). Hemorrhagic shock was simulated under light Nembutal (25 mg/kg) anesthesia by acute massive hemorrage (AMH) of 2.5 ml/100 g at a rate of 2 ml/min (30% of blood volume) from the tail artery where catheter was installed for the direct measurement of arterial pressure (AP). After the bloodletting AP average was in the range of 40-50 mm Hg. Without any pharmacological support.
1 h after the AMH there was the replenishment of hypovolemia with the selected agent in the volume of 200% of blood loss: in the control series (n=18) — with Ringer's solution, in the experimental series (n=18) — Sterofundin isotonic (B/Braun, Germany ). The time of drug injection was 60 min. Within the following 60 minutes the blood
For contacts: Yakovlev Alexey Yurievich, phone: 8(831)438-93-33, +7 903-608-57-37, +7 951-910-57-31; e-mail: [email protected]
Pancreatoprotection in Experimental Hemorrhagic Shock СТМ 1 2013 — 5(2) 25
BIOMEDICAL INVESTIGATIONS
was reinfused in the volume of 70% of the blood loss. The animals were removed from the experiment in 24 and 72 h after the blood loss. Before the light optical microscopy of tissue histologic specimen were fixed in 10% neutral formalin 72-96 hours, dehydrated in spirits of ascending concentration and embedded into paraffin. 7 pm thick sections were produced on a Leica SM 2000R (Germany) microtome and stained with hematoxylin and eosin. The view of histologic specimen was performed with the microscope Leica DMLS (Germany). Photomicrographs were obtained by video-based computer with a Pentium III CCD camera. Assessment of studied biochemical parameters (glucose, lactate, LDH, amylase) was carried out with biochemical analyzer Konelab 60i (Finland) using Thermo scientific reagents (Finland). Statistical processing of the results was performed using the programs Microsoft Excel and Statistica 6.0 following the criteria of nonparametric statistics, using the criterion of inter-group comparison, Kruskal-Wallis ANOVA.
Results. Morphological studies of the pancreas conducted a day after the removal of rats from hemorrhagic shock in animals treated with Ringer's solution, showed the presence of edema of the stroma, pericellular edema
in the islets of Langerhans, the expansion of the ducts of exocrine glands (See Fig., a). Using malate-containing Sterofundin isotonic solution as a single agent of infusion therapy significantly reduced the edema of the stroma of the pancreas in the absence of pericellular edema in the islets of Langerhans and perivascular edema (See Fig., b). Consequently, blood malate-containing substitutes contributed prevention of early reperfusion injuries of the pancreas. On the third day of post-hemorrhagic period in animals of the control series the morphological changes of the pancreas increased progressively (See Fig., c). Defined stroma and capsule edema, perivascular edema, pericellular edema in the islets of Langerhans, the expansion of the ducts of exocrine glands were detected. Most vessels contain only plasmatic components indicating the microcirculatory disorders in the pancreas.
In the test series the increase in stromal edema of the pancreas was observed, perivascular edema, pericellular edema was observed in the islets of Langerhans (See Fig., d). The blood stagnation was noticed in the vascular bed. The increase in the severity of the morphological changes in the test and to in the control series are primarily due to the late reperfusion changes. But this
Structure of pancreas: a — Ringer solution, day 1; b — Ringer solution, day 3; c — Sterofundin isotonic solution, day 1; d — Sterofundin isotonic solution, day 3. Stained with hematoxylin and eosin; a, c, d — X100; b — X40
уттжтжтжтжттттжтжтжтжтттт^ттттжтттт^тттт^тититттттиттг/'
26 СТМ J 2013 — 5(2) A.Y. Yakovlev, L.B. Snopova, Т.А. Galanina, D.V. Ryabikov, D.M. Protasov
BIOMEDICAL INVESTIGATIONS
The change of biochemical parameters in the blood serum of rats after acute massive blood loss (M±SD)
Observation period Glucose Lactate Glucose\lactate LDH Amylase Са2+
Ringer solution
Day 1 8.47±1.53 3.92±0.52 2.18±0.32 752.1±128.8 1378.1±262.5 1.10±0.05
Day 3 7.83±1.01 3.10±0.38 2.48±0.20 792.2±156.8 885.0±240.5* 0.56±0.10
Sterofundin isotonic
Day 1 7.34±1.89 3.39±0.48 2.16±0.40 484.7±95.4## 804.0±149.7## 1.22±0.02
Day 3 6.35±0.73*# 2.31±0.35*## 2.82±0.28*# О ■^r о +1 CM о CO LO 508.5±151.1**# 0.82±0.08
Note: statistically significant difference of values with the first 24 h. * — p<0.05,** — p<0.01; # — p<0.05, ** — p<0.01 — with the control group.
does not exclude the influence of the pancreas of other organs of the gastrointestinal tract involved in multiple organ dysfunction, including bowel and liver. [7]
The analysis of the results of basic laboratory indicators characterizing ischemic and subsequent reperfusion injury of the pancreas [8, 9] (see the Table), showed that in the early posthemorrhagic period, all animals showed marked changes in carbohydrate metabolism, hyperglycemia, hyperlactatemia, decrease of index “glucose/lactate”. They regressed significantly more rapidly in animals of experimental series, and that confirms antihypoxic activity of malate, being contained Sterofundin isotonic. The rate of decline of hyperlactatemia was higher than those of other metabolic parameters. Presented in animals of the control series hyperglycemia on day 3 was the reflection of not only post agressive insulin resistance, but also of the endocrine dysfunction of the pancreas, confirmed by the morphological picture of the islets of Langerhans.
High indexes of enzymemia in animals of the control group within posthemorrhagic period show the degree of necrotic damage of internal organs cells. Hyperamylasemia along with hypocalcaemia confirmed the special vulnerability of the pancreas to ischemic injury, and lactate dehydrogenase indexes persisting for three days were greater than 750 units, and in addition it proved the high probability of the development of destructive forms of acute pancreatitis. Postischemic hyperenzymemia in animals of the experimental group was significantly lower due to cytoprotective and membrane protective properties of exogenously administered malate by supporting energy production in the citric acid cycle and malate-aspartate shunt. The known association of metabolism of malate and succinate does not preclude correction of energy shortage by increasing the bioavailability of succinate cells [10-12]. Reducing the severity of cytolytic syndrome confirms the importance of the substrate support mechanisms malate-dependent mechanisms of organ-protection with Sterofundin isotonic.
Reducing the severity of morphological and laboratory manifestations of acute pancreatitis using Sterofundin isotonic we associate with recovery oxigen-dependent bioenergetic processes in the cell along with the delayed complex protective action of malate on adaptation mechanisms after AMH [13-14].
conclusion. Malate-containing blood substitute Sterofundin isotonic, used in the early stages of the experimental treatment of acute massive blood loss, and has a preventive effect on the development of pancreatic injuries in the early and delayed posthemorrhagic periods.
References
1. Alam H.B., Rhee P. New development in fluid resuscitation. Surg Clin North Am 2007; 87(1): 55-72.
2. Donat R. Spahn, Vladimir Cerny, Timothy J. Coats, Jacques Duranteau, Enrique Fernandez-Mondejar, Giovanni Gordini, et al. Management of bleeding following major trauma: a European guideline. Crit Care 2007 April 24; 11(2): 414.
3. Schmid-Schonbein G.V., Delano F.A., Penn A.N., Kistler E. An elementary analysis of physiologic shock and multi-organ failure: the autodigestion hypothesis. Conf Proc IEEE Eng Med Biol Soc 2012 Aug; 2012: 3114-3115.
4. Yang J.F., Sun L.M., Wang X.F., Dai N. Massive gastrointestinal bleeding from Meckel diverticulum with ectopic pancreatic tissue. Chin Med J (Engl) 2011 Feb; 124(4): 631-633.
5. Kovacs J., Gursu S., Jung J., Szederiesi J., Copotoiu R., Azamfieri L. Clinico-pathological particularities of the shock-related pancreatitis. Pathol Oncol Res 2012 Oct; 18(4): 977-981.
6. Moroz V.V. Strategiya i taktika primeneniya antigipoksantov pri kriticheskikh sostoyaniyakh. V kn.: Fundamentafnye problemy reanimatologii (izbrannye lektsii i obzory). Trudy instituta obshchey reanimatologii RAMN [Strategy and tactics of using antihypoxic agents in critical conditions. In: Fundamental problems of emergency medicine (selective lectures and reviews). Proceedings of Research Institute of General Reanimatology of RAMS]. Vol. IV. Moscow; 2005; p. 210-220.
7. Ermolov A.S., Popova T.S., Pakhomova G.V., Uteshev N.S. Sindrom kishechnoy nedostatochnosti v neotlozhnoy abdominafnoy khirurgii (ot teorii k praktike) [Malabsorption syndrome in emergency abdominal surgery (from theory to practice)]. Moscow: Medekspertpress; 2005; 460 p.
8. Dolgikh V.T., Ershov A.V., Shikunova L.G. K patogenezu serdechnoy nedostatochnosti pri pankreonekroze (eksperimental'noe issledovanie) [About the pathogenesis of cardiac failure in pancreatonecrosis (experimental study)]. Obshchaya reanimatologiya — General Reanimatology 2009; 3: 39-44.
9. Egea-Guerrero J.J., Revuelto-Rev J., Martin-Bermudes R., Domingues-Roldan J.M. Elevated serum pancreatic enzyme levels after hemorrhagic shock, every variable under control? J Travma 2010 Apr; 68(4): 1016.
10. Luk'yanova L.D. Sovremennye problemy adaptatsii k gipoksii. Signal'nye mekhanizmy i ikh rol' v sistemnoy regulyatsii. Patologicheskaya fiziologiya i eksperimental'naya terapiya [Modern problems of adaptation to hypoxia. Signal mechanisms
Pancreatoprotection in Experimental Hemorrhagic Shock СТМ 1 2013 — 5(2) 27
BIOMEDICAL INVESTIGATIONS
and their role in systemic regulation]. Patologicheskaya fiziologiya i eksperimental’naya terapiya — Pathological Physiology and Experimental Therapy 2011; 1: 3-19.
11. Maevskiy E.I., Grishina E.V., Rozenfel'd A.S., et al. Anaerobnoe obrazovanie suktsinata i oblegchenie ego okisleniya — vozmozhnye mekhanizmy adaptatsii kletki k kislorodnomu golodaniyu [Anaerobic succinate formation and of easening of its oxidation — possible mechanisms of cell adaptation to hypoxia]. Biophysics 2000; 45(3): 509-513.
12. Hamada T., Yamamoto M., Naramaru K., et al. The
farmakokinetics of D-lactate, L-lactate, malate and acetate in humans. Masui 1997; 46: 229-236.
13. Luk'yanova L.D. Rol' bioenergeticheskikh narusheniy v patogeneze gipoksii [The role of bioenergetic disorders in hypoxia pathogenesis]. Patologicheskaya fiziologiya i eksperimental’naya terapiya — Pathological Physiology and Experimental Therapy 2004; 2: 2-11.
14. Lukyanova L.D., Germanova E.L., Kirova Ya.I. In: Adaptation Biology and Medicine. Vol. VI. New Delhi: Narosa Publishing House; 2011; p. 251-277.
