Efficacy of 17>-ethynylestradiol-3-sulfate for severe hemorrhage in minipigs in the absence of fluid resuscitation Matthew Miller, DVM, James Keith, DVM-PhD, Jonathan Berman, MD, PhD, D. Bruce Burlington, MD, Charles Grudzinskas, PhD, William Hubbard, PhD, Carl Peck, MD, Charles Scott, PhD, and Irshad H. Chaudry, PhD, North Potomac, Maryland BACKGROUND: Of the potentially survivable US battlefield deaths from 2001 to 2011, 80% to 91% were caused by severe hemorrhage. We subjected minipigs to acute severe blood loss, administered a single dose of 17>-ethynylestradiol-3-sulfate (EE-3-SO 4 ) without resuscitative fluids, and determined survival as well as cardiovascular, biochemical, and physiologic response parameters. METHODS: Following controlled removal of 60% circulating blood volume over 1 hour, minipigs received EE-3-SO 4 at 0, 1, 3, or 5-mg/mL saline per kilogram of body weight in Experiment 1 (n = 25) and 0-, 0.1-, 0.3-, or 1-mg/mL saline per kilogram in Experiment 2 (n = 23). Survival times and response parameters were recorded for the next 6 hours. RESULTS: Median survival times of the minipigs receiving 1 mg/kg (257 minutes and 360 minutes) were 1.8 times and 5 times those of the control group (140 minutes and 65 minutes) in Experiments 1 and 2, respectively. For both experiments combined, the log-rank p value was 0.0002, and the number of animals alive at 6 hours was 6 (50%) of 12 in the 1-mg/kg groups versus 0 (0%) of 12 in the control groups. Early increases in glucose, lactate, potassium, and phosphate as well as decreases in bicarbonate and mean arterial pressure correlated with shorter survival times. CONCLUSION: Administration of a single dose of 1-mg/kg EE-3-SO 4 in 1-mL/kg of saline following severe hemorrhage increased survival in 60% acutely bled minipigs by 3.5-fold. Slightly elevated blood pressure values, more physiologic values of oxidative phosphorylation parameters, and lower elevations of possible tissue necrosis parameters correlated with longer survival time. These results support the further product development of EE-3-SO 4 for the indication of severe hemorrhage when standard resuscitative fluids are not available. (J Trauma Acute Care Surg. 2014;76: 1409Y1416. Copyright * 2014 by Lippincott Williams & Wilkins) KEY WORDS: Estrogen; blood loss; cardiovascular responses; metabolic responses; fluid administration; swine. O f the 4,596 battlefield deaths experienced by the US Armed Forces from 2001 to 2011, 87% occurred before reaching medical treatment facilities. Twenty-four percent of the premedical facility deaths were potentially survivable, with an overwhelming number (80Y91%) of the potentially sur- vivable deaths being caused by acute hemorrhage. 1,2 The lack of measures to treat hemorrhagic shock on the battlefield is an unmet medical need ‘‘that has been present for the entire his- tory of warfare and well documented for nearly a century.’’ 1 Treatment of hemorrhagic shock is particularly difficult in remote environments where standard recommendations for re- suscitative fluids 3 cannot be implemented. In remote regions, large fluid volumes cannot be routinely carried in medical packs, and evacuation times to facilities where fluids are available are extended because of terrain or lack of air superiority. To deal with this battlefield issue, the Department of Defense Hemorrhage and Resuscitation Research and Development Steering Com- mittee, which is responsible for the strategic level coordination, review, and planning for Department of Defense research and development programs in hemorrhage and resuscitation, has issued a priority requirement for the development of a low- volume medical countermeasure for hemorrhage. A further re- quirement is a highly water-soluble drug, since drugs must be administered either intravenously or intraosseously for severe hemorrhage. The hypothesis that female sex hormones (estrogens) may improve cardiovascular functions and thus promote sur- vival after trauma-hemorrhage is based on extensive rodent studies 4Y9 and some observational clinical data. 10Y12 Although estrogens such as 17A-estradiol are not water soluble, estrogen sulfates are highly soluble. Swine models of trauma-hemorrhagic shock are similar to those following hemorrhagic shock in humans with respect to cardiovascular and hemodynamic re- sponses. 13 Following successful studies with a variety of estrogen sulfates in rodents (Chaudry et al, unpublished data), we eval- uated estrogen sulfates in a swine model 14 of severe hemorrhage and prolonged hypotension without fluid resuscitation. A single dose of 9-mg/kg Premarin (sulfated estrogens extracted from the urine of pregnant mares) showed some efficacy (Miller et al., unpublished data), but an estrogen that is more potent at a lower dose/fluid volume was desired for anticipated austere clinical situations. 17>-Ethynylestradiol-3 sulfate (EE-3-SO 4 , Fig. 1) is the sulfate of 17>-ethynylestradiol (EE), the synthetic estrogen ORIGINAL ARTICLE J Trauma Acute Care Surg Volume 76, Number 6 1409 Submitted: January 15, 2014, Revised: February 12, 2014, Accepted: February 12, 2014. From the Texas A&M Institute for Preclinical Studies (M.M.), Texas A&M Uni- versity, College Station, Texas; Keith Pharmacology Research Group, LLC (J.K.), Andover, Massachusetts; Fast-Track Drugs and Biologics, LLC (J.B., C.S.), North Potomac, Maryland; NDA Partners, LLC (D.B.B., C.G., C.P.), Falls Church, Virginia; and Department of Surgery (W.H., I.H.C.), University of Alabama at Birmingham, Birmingham, Alabama. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com). Address for reprints: Jonathan Berman, MD, PhD, Fast-Track Drugs, 7 Paramus Ct, North Potomac, MD; email: jberman@fasttrackresearch.com. DOI: 10.1097/TA.0000000000000237 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.