Resuscitation-Induced Pulmonary Apoptosis and
Intracellular Adhesion Molecule-1 Expression in Rats
Are Attenuated by the Use of Ketone
Hasan B Alam,
, Brenda Austin,
, Elena Koustova,
, Peter Rhee,
Resuscitation with Lactated Ringer’s solution after hemorrhagic shock in rats has been shown to
cause early cellular injury in the lung. We hypothesized that the use of energy substrates, such as
ketone bodies, in the resuscitation fluids would protect against this injury. As markers of cellular
injury we measured the induction of apoptotic cell death and the expression of Intracellular
Adhesion Molecule-1 (ICAM-1).
Male Sprague Dawley rats (n ϭ 35) under inhaled isoflurane anesthesia had placement of
femoral arterial and venous catheters. A three-stage hemorrhage model was used for this exper-
iment. There was an initial hemorrhage of 27 mL/kg for 10 minutes. During the next 75 min-
utes another 8 mL/kg of blood was withdrawn at a steady rate. The resuscitation fluids were
then infused for 45 minutes during which the third continuous hemorrhage of 8 mL/kg was
performed. The animals were randomized to five groups: 1) sham hemorrhage (n ϭ 6); 2) sham
resuscitation (n ϭ 7); 3) Lactated Ringer’s resuscitation, three times the volume of shed blood
(n ϭ 8); 4) Ketone Ringer’s (containing 28 mEq/L of
-hydroxybutyrate) resuscitation, three
times the volume of shed blood (n ϭ 7); and 5) plasma resuscitation, volume equal to shed
blood (n ϭ 7). The animals were sacrificed 1 hour after resuscitation and lungs were harvested.
Western blot technique was used for the determination of proapoptotic protein (bax), antiapop-
totic protein (bcl-2), apoptotic fragments of poly ADP-ribose polymerase, and ICAM-1. Sec-
tions of lung were also subjected to immunostaining using antibodies to bax and ICAM-1
proteins (reported as number of positive cells/mm
Lactated Ringer’s resuscitation caused a significant increase in pulmonary apoptosis and
ICAM-1 expression compared with the sham hemorrhage group. Animals resuscitated with
Ketone Ringer’s solution and plasma did not show this injury pattern.
Substitution of lactate with ketone bodies in the resuscitation fluid attenuates the expression of
cellular injury markers in the lung. (J Am Coll Surg 2001;193:255–263. © 2001 by the
American College of Surgeons)
Numerous clinical and animals studies in recent years
have challenged the time-honored paradigm of rapid,
high-volume crystalloid fluid resuscitation for hemor-
It is now being recognized that resusci-
tation fluids may actually potentiate the cellular injury
caused by hemorrhagic shock. We have previously dem-
onstrated, in a swine model of hemorrhagic shock, that
resuscitation with Lactated Ringer’s (LR) solution causes
increased neutrophil oxidative burst activity.
study, no significant neutrophil activation was seen after
fresh whole blood or hypertonic saline resuscitation. In-
This research was supported by a grant from the Office of Naval Research—
The opinions and assertions contained here are the private ones of the authors
and are not to be construed as official or reflecting the views of the Department of
Defense at large. This article was prepared by United States Government employ-
ees and cannot be copyrighted and may be copied with restriction.
Abstract presented at the 86
Annual Clinical Congress, American College of
Surgeons Surgical Forum, Chicago, IL, October 2000.
Received January 4, 2001; Revised April 17, 2001; Accepted April 24, 2001.
From the Department of Surgery, Uniformed Services University of the
Health Sciences, Bethesda, MD (Alam, Austin, Koustova, Rhee) and Depart-
ment of Surgery, Washington Hospital Center, Washington, DC (Alam, Rhee).
Correspondence address: Peter Rhee, MD, MPH, FACS, Department of
Surgery, USUHS, 4301 Jones Bridge Rd, Bethesda, MD 20814.
© 2001 by the American College of Surgeons ISSN 1072-7515/01/$21.00
Published by Elsevier Science Inc. PII S1072-7515(01)01004-3