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. 2018 Sep 17;8(1):89.
doi: 10.1186/s13613-018-0436-0.

Performance of closed-loop resuscitation of haemorrhagic shock with fluid alone or in combination with norepinephrine: an experimental study

Nicolas Libert  1   2 , Guillaume Chenegros  3 , Anatole Harrois  1   4 , Nathalie Baudry  1 , Gilles Cordurie  3 , Ryad Benosman  3 , Eric Vicaut  1   5 , Jacques Duranteau  6   7
Affiliations

Performance of closed-loop resuscitation of haemorrhagic shock with fluid alone or in combination with norepinephrine: an experimental study

Nicolas Libert et al. Ann Intensive Care. .

Abstract

Background: Closed-loop resuscitation can improve personalization of care, decrease workload and bring expert knowledge in isolated areas. We have developed a new device to control the administration of fluid or simultaneous co-administration of fluid and norepinephrine using arterial pressure.

Method: We evaluated the performance of our prototype in a rodent model of haemorrhagic shock. After haemorrhagic shock, rats were randomized to five experimental groups: three were resuscitated with fluid and two with co-administration of fluid and norepinephrine. Among groups resuscitated with fluid, one was resuscitated by a physician and two were resuscitated according to two different closed-loop algorithms. Among groups resuscitated with fluid and norepinephrine, one was resuscitated by a physician and the other one by the closed-loop device. The precision of arterial pressure during the resuscitation period was assessed using rising time, time passed in the target area and performance error calculations.

Results: Groups resuscitated with fluid had similar performances and passed as much time in the target area of 80-90 mmHg as the manual group [manual: 76.8% (67.9-78.2), closed-loop: 64.6% (45.7-72.9) and 80.9% (59.1-85.3)]. Rats resuscitated with fluid and norepinephrine using closed-loop passed similar time in target area than manual group [closed-loop: 74.4% (58.4-84.5) vs. manual: 60.1% (46.1-72.4)] but had shorter rising time to reach target area [160 s (106-187) vs. 434 s (254-1081)] than those resuscitated by a physician. Rats resuscitated with co-administration of fluid and norepinephrine required less fluid and had less hemodilution than rats resuscitated with fluid alone. Lactate decrease was similar between groups resuscitated with fluid alone and fluid with norepinephrine.

Conclusions: This study assessed extensively the performances of several algorithms for closed-loop resuscitation of haemorrhagic shock with fluid alone and with co-administration of fluid and norepinephrine. The performance of the closed-loop algorithms tested was similar to physician-guided treatment with considerable saving of work for the caregiver. Arterial pressure closed-loop guided algorithms can be extended to combined administration of fluid and norepinephrine.

Keywords: Closed-loop; Fluid; Haemorrhagic shock; Norepinephrine; Resuscitation.

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Figures

Fig. 1
Fig. 1
Experimental protocol. The continuous line represents the evolution of MAP during the two phases of the study (acute exsanguination followed exsanguination or transfusion to maintain MAP between 30 and 35 mmHg). Time is represented on the horizontal arrow. Each phase lasted 60 min. ABG arterial blood gas, M-F manual fluid group, CL-PI closed-loop PI group, CL-FL closed-loop FL group, M-FNE manual fluid and norepinephrine group, CL-FNE closed-loop fluid and norepinephrine group
Fig. 2
Fig. 2
Schematic of the system set-up. The CL-FNE combined a PI regulator for fluid and a FL regulator for NE. Several conditional rules were included to mimic the physician decisions. The algorithm needed three variables: systolic arterial pressure, systolic arterial pressure error and time. During resuscitation, it calculates the ratio of fluid volume/norepinephrine to adapt therapy
Fig. 3
Fig. 3
Systolic arterial pressure (mmHg) over time in groups resuscitated with fluid (a) and in groups resuscitated with combination of fluid and norepinephrine (b). M-F manual fluid, CL-PI closed-loop fluid with a PI algorithm, CL-FL closed-loop fluid with a fuzzy logic algorithm, M F-NE manual fluid and norepinephrine, CL F-NE closed-loop fluid and norepinephrine
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