Pharmacology in Emergency Medicine TERLIPRESSIN WITH LIMITED FLUID RESUSCITATION IN A SWINE MODEL OF HEMORRHAGE John J. Devlin, MD, CDR, MC, USN,* Sara S. DeVito, BS, LATG,* Lanny F. Littlejohn, MD, CDR, MC, USN,* Miguel A. Gutierrez, MD, CDR, MC, USN,* Gosia Nowak, MSC, MPH,† Jose ´ Henao, MD, CDR, USN,* Anthony Bielawski, MD, CDR, USN,* Joseph Kotora, DO, CDR, USN,* and Andrew S. Johnson, MD, CAPT, MC, USN* *Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia and †Navy and Marine Corps Public Health Center, Portsmouth, Virginia Reprint Address: John J. Devlin, MD, CDR, MC, USN, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30342 , Abstract—Background: Principles of damage control resuscitation include minimizing intravenous fluid (IVF) ad- ministration while correcting perfusion pressure as quickly as possible. Recent studies have identified a potential advan- tage of vasopressin over catecholamines in traumatic shock. Terlipressin (TP) is a vasopressin analogue used to reverse certain shock etiologies in some European countries. Study Objective: We evaluated three dosages of TP when com- bined with a limited colloid resuscitation strategy on mean arterial pressure (MAP) and lactatemia in a swine model of isolated hemorrhage. Methods: Sixty anesthetized swine underwent intubation and severe hemorrhage. Subjects were randomized to one of four resuscitation groups: 4 mL/kg Hextend Ò (Hospira Inc, Lake Forest, IL) only, 3.75 mg/kg TP + Hextend, 7.5 mg/kg TP + Hextend, or 15 mg/kg TP + Hextend. MAP and heart rate were recorded every 5 min. Baseline and serial lactate values at 30-min in- tervals were recorded and compared. Results: Subjects re- ceiving 7.5 mg/kg TP had significantly higher MAPs at times t 15 (p = 0.012), t 20 (p = 0.004), t 25 (p = 0.018), t 30 (p = 0.032), t 35 (p = 0.030), and t 40 (p = 0.021). No statistically significant differences in lactate values between TP groups and controls were observed. Conclusion: Subjects receiving 7.5 mg/kg of TP demonstrated improved MAP within 10 min of administration. When combined with minimal IVF resus- citation, TP doses between 3.75 and 15 mg/kg do not elevate lactate levels in hemorrhaged swine. Published by Elsevier Inc. , Keywords—terlipressin; hemorrhage; military; shock; resuscitation; damage control INTRODUCTION During hemorrhagic shock, data strongly suggest that perfusion pressure should be restored as soon as possible and that delays in correcting hypotension in the field worsen outcomes (1,2). Conventional practice reserves vasopressor use for patients who fail to respond to intravascular repletion with intravenous fluids (IVF), either crystalloid or colloid. The practice reflects concern that if cardiac filling pressures are not optimized before vasopressor administration, excessive vasoconstriction ensues, leading to a paradoxical decrease in vital organ blood flow and elevated lactate levels. For this reason, IVF resuscitation has been the mainstay of field shock reversal during the last century. Civilian and military medical communities have now embraced limited fluid resuscitation as the ideal strategy Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. RECEIVED: 9 June 2012; FINAL SUBMISSION RECEIVED: 26 November 2012; ACCEPTED: 19 December 2012 78 The Journal of Emergency Medicine, Vol. 45, No. 1, pp. 78–85, 2013 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2012.12.023