There are consistent data showing significant RBC deformability and shape abnormalities in septic shock and sepsis (21,22), burn shock and burns (23,24), cardiogenic shock (25), as well as during blood storage (26). The effects of hemorrhagic shock on RBC morphological and rheological properties are much less widely studied, and the results that have been obtained are contradictory (2–5). We believe that these contradictory observations are related to the confounding effects of the various methodologies used in these studies. LORCA is considered to be one of the most reliable techniques to measure RBC deformability. It has been compared with other methods of measuring RBC deformability. Our previous work has shown that Reid filtration technique results correlate with LORCA data (27). However, filtration methods require removal of WBC, which can significantly influence the results. Different washing procedures may not be sufficiently effective to completely remove WBC from RBC suspensions (28). In addition, the Reid filtration method requires a larger volume of blood for each study, and cannot be used for repeated measurements. Computerized cell transit analyzer (CTA) is a new generation cell filtration system, which is less sensitive to WBC-related artifacts. However, this method appeared to be not sensitive enough to detect those sepsis-induced RBC deformability changes that were identified by LORCA (6). Because these methodological concerns can be obviated by the use of LORCA, we used this system to evaluate the effects of trauma-hemorrhage on RBC deformability. It should be also mentioned that LORCA indices correlate with physiologic effects by other investigators. The decrease in RBC deformability (evaluated with LORCA EI) seen in patients with arterial hypertension was associated with a decrease in cellular oxygen delivery and tissue oxygenation (18). Treatment of patients who had arterial hypertension and hypercholesterolemia with calcium antagonists, cholesterol decreasing agents, and low calorie diet led to normalization of the blood pressure and lipid parameters, as well as to normalization of the RBC elongation index (20).
Our data demonstrated a significant decrease in RBC deformability at the end of the 90-min shock period prior resuscitation as well as after volume resuscitation (reperfusion phase). Restoration of a normal arterial pressure did not improve RBC deformability, which remained low through the 6 h of the postresuscitation period. These RBC deformability changes were primarily observed only at low shear stresses less than 1.0 Pa. In LORCA, RBC are exposed to temperature and shear stresses similar to those observed in the circulation. The spectrum of shear stresses used in this device varies from 0.30 to 30 Pa. In vivo studies performed by different investigators have documented that shear stresses along the microcirculatory bed are close to the values mentioned above (29–31). The lowest shear stresses have been found in true capillaries (0.8–3 Pa) and venules (0.5–2 Pa). In arterioles, shear stress is significantly higher and ranges from 8 to 10 Pa to 20 to 30 Pa in shunting arterioles. Based on these data, we conclude that RBC deformability changes found at low shear stresses can have substantial impact on capillary and postcapillary blood flow.
Taken together, our deformability and morphologic results indicate that, similar to deformability changes, RBC shape alterations can be detected at the end of shock and that they persist during 6 h of the postresuscitation period. RBC shape transformation was mainly of the reversible echinocyte type. It should be mentioned that our experimental design did not allow us to determine exactly when shock-induced shape alterations started because the first blood sample was taken for morphologic examination after 90 min of shock. However, our previous studies in a canine model of rapid hemorrhage (34) showed that significant RBC shape alterations already existed after 10 min of massive blood loss.
Of potential clinical importance, our data showed that in the subgroup of decompensated rats, which had a 50% mortality rate in the postshock period, RBC deformability at the end of shock was significantly lower compared with the compensated animals, all of which survived the experimental period. This observation indicates an association between impaired RBC deformability and an adverse outcome. Furthermore, these results are consistent with the clinical data of Langenfeld et al. (39) obtained in patients with trauma, where the authors demonstrated that changes in deformability after trauma preceded the development of infectious complications by several days and occurred significantly earlier than the usual clinical indicators of infection, such as fever and leukocytosis. The fact that not only different species of animals (40), but different representatives of the same specie (41,42) may have different tolerance and variability in hemodynamic response to hemorrhage has been discussed in the literature. One of the explanations is a difference in sympatic nerve activity (43). Whether there exists a genetic predisposition to this phenomenon needs to be determined.
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