J Appl Physiol 118: 7179, 2015.

First published October 23, 2014; doi:10.1152/japplphysiol.00727.2014.

Cardiovascular parameters in a mixed-sex swine study of severe

decompression sickness treated with the emulsified perfluorocarbon Oxycyte
R. T. Mahon, W. A. Cronin, M. Bodo, S. Tirumala, D. P. Regis, and C. R. Auker
Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland
Submitted 12 August 2014; accepted in final form 16 October 2014

Mahon RT, Cronin WA, Bodo M, Tirumala S, Regis DP, Auker

CR. Cardiovascular parameters in a mixed-sex swine study of severe
decompression sickness treated with the emulsified perfluorocarbon
Oxycyte. J Appl Physiol 118: 7179, 2015. First published October
23, 2014; doi:10.1152/japplphysiol.00727.2014.Intravenous perfluorocarbons (PFC) have reduced the effects of decompression sickness (DCS) and improved mortality rates in animal models. However,
concerns for the physiological effects of DCS combined with PFC
therapy have not been examined in a balanced mixed-sex population.
Thirty-two (16 male, 16 female) instrumented and sedated juvenile
Yorkshire swine were exposed to 200 feet of seawater (fsw) for 31
min of hyperbaric air. Pulmonary artery pressure (PAP), cardiac
output (CO), and systemic arterial pressure (SAP) were monitored
before (control) and after exposure. Animals were randomized to
treatment with Oxycyte (5 ml/kg; Oxygen Biotherapeutics, Inc.,
Morrisville, NC) vs. saline (control) with 100% oxygen administered
upon DCS onset; animals were observed for 90 min. Parameters
recorded and analyzed included PAP, CO, and SAP. In all animals
PAP began to rise prior to cutis marmorata (CM) onset, the first sign
of clinical DCS, generally peaking after CM onset. Female swine,
compared with castrated males, had a more rapid onset of CM (7.30
vs. 11.46 min postsurfacing) and earlier onset to maximal PAP (6.41
vs. 9.69 min post-CM onset). Oxycyte therapy was associated with a
sustained PAP elevation above controls in both sexes (33.41 vs. 25.78
mmHg). Significant pattern differences in PAP, CO, and SAP were
noted between sexes and between therapeutic groups. There were no
statistically significant differences in survival or paralysis between the
PFC and control groups during the 48-h observation period. In
conclusion, Oxycyte therapy for DCS is associated with a prolonged
PAP increase in swine. These species and sex differences warrant
further exploration.
swine; decompression sickness; perfluorocarbon emulsion
WHILE THERE IS NO definitive etiology of decompression sickness
(DCS), it is believed that bubble formation as a result of rapid
decompression initiates a cascade of undefined events leading
to the manifestation of DCS (11). In cardiopulmonary DCS,
bubble formation can cause right heart failure (7) or compromise blood flow to critical tissue beds such as the central
nervous system (17). Standard therapy for DCS is recompression followed by controlled, staged decompression in a hyperbaric chamber. However, DCS onset is most often geographically remote from advanced medical assets, particularly assets
that include hyperbaric chambers. This is certainly true in
disabled submarine rescue and some recreational diving. Methods to mitigate the effects of DCS without hyperbaric chambers may improve clinical outcomes as there is evidence to

Address for reprint requests and other correspondence: R. T. Mahon,

Undersea Medicine Dept., Naval Medical Research Center, 503 Robert Grant
Ave., Silver Spring, MD 20910-7500 (e-mail: Richard.Mahon@med.navy.
mil).
http://www.jappl.org

suggest adverse effects of delaying recompression on severe

DCS (1, 8, 15, 25).
Perfluorocarbons (PFCs) are synthetic fluorinated hydrocarbons that have shown benefit in preventing and treating the
manifestations of severe DCS in animal models. Compared
with normal saline or plasma, PFCs can carry several times as
much respiratory gas (such as oxygen and nitrogen) (34).
Hence, when emulsified for intravenous (IV) delivery, PFCs
appear as ideal compounds to treat the bubble formation
component of DCS by facilitating nitrogen elimination and
enhancing oxygen delivery to tissue that may have decreased
blood flow (3, 16, 19, 41). In swine and rodent models, IV
emulsified PFCs have reduced severe DCS incidence when
used prior to onset, and reduced mortality when administered
after onset (9, 27, 33).
However, one concern for PFC emulsions is its association
with an increase in pulmonary artery pressure (PAP) observed
in certain species (16, 32, 35). This finding has been attributed
to pulmonary macrophages and complement activation (14,
37). Since severe DCS is also associated with elevated PAP,
there is a rational concern for any deleterious effects of PFC
treatment. In large-animal studies evaluating this disease/treatment combination, mean PAP did not appear elevated above
control therapy in swine, yet did appear elevated above control
therapy in a sheep DCS model (32, 35).
The studies cited used unbalanced mixed-sex populations.
Sex-related studies of DCS onset and severity have yielded
conflicting results and to our knowledge sex differences in PFC
therapy have not been examined (2, 39). This balanced mix-sex
swine study aims to primarily evaluate the cardiovascular
effects of sex differences and treatment with the PFC emulsion,
Oxycyte (Oxygen Biotherapeutics, Inc., Morrisville, NC), at a
dose of 5 ml/kg following onset of DCS.
We hypothesized that Oxycyte will improve the hemodynamic profile (especially PAP) when used in the treatment of
severe DCS.
METHODS

The study protocol was reviewed and approved by the Walter Reed
Army Institute of Research/Naval Medical Research Center Institutional Animal Care and Use Committee in compliance with all
applicable Federal regulations governing the protection of animals in
research. The institutional animal care facility is fully AAALAC
accredited, and the veterinary staff is familiar with our swine model
for DCS.
Swine were purchased from a single vendor and acclimatized for a
minimum of 5 days prior to experimentation. Swine were housed
singly and fed 22.5% of body weight twice daily (Lab diet Mini Pig
Grower, Quality Lab Products, Elkridge MA); water was provided ad
libitum. On the evening prior to the experiment the animal was fasted
overnight but allowed free access to water.
71

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Cardiovascular Parameters in Swine Treated with PFC for DCS

Mahon RT et al.

Surgical Preparation of Swine

Hyperbaric Chamber

Thirty-two Yorkshire swine (16 male; 16 female; 25.20 2.28 kg)

were randomized into four groups: 1) PFC/Males were males treated
with PFC; 2) Saline/Males were control males treated with normal
saline; 3) PFC/Females were females treated with PFC; and 4)
Saline/Females were control females treated with saline. On the day of
experiment, swine were transported in a kennel to a surgical preparation room where they were premedicated with ketamine (10 20
mg/kg; Vedco, Saint Joseph, MO) and xylazine (12 mg/kg im;
Akom, Decatur, IL) and intubated after further induction with inhaled
isoflurane via a snout cone. An ear vein was catheterized (20 22
gauge 1 in.) for intravenous access (fluid maintenance and medication administration). In the prone position swine were shaved for
electrode and sensor placement.
Subsequently, each animal was taken into the surgical room and
placed in the supine position. Anesthesia was maintained with inhaled
isoflurane (2%) in room air via a GE S5 ADU Carestation (GE
Healthcare, Madison, WI). The right superficial femoral artery was
exposed and a 12-in. PE-90 catheter (ReCathCo Allison Park, PA)
was introduced into the artery and advanced centrally into the femoral
artery for blood sampling. In similar fashion the left superficial
femoral arterial branch was accessed and a pressure transducer (for
continuous blood pressure monitoring) was inserted (Mikro-Tip Pressure Catheters; Millar Instruments, Houston, TX). Simultaneous to
arterial catheterization, a pulmonary artery catheter was introduced
via surgical exposure of the right external jugular vein (CCOmbo V
7.5 F; Edwards Lifesciences, Irvine, CA). If the right jugular vein was
unusable for any reason during catheterization, the process was
repeated on the left side. After completing the surgical procedures the
animal was placed in a Panepinto sling, Buprenorphine (Buprenex, 0.1
mg/kg im) was administered, isoflurane anesthesia was discontinued,
and the animal was extubated. The animal was then transported in the
Panepinto sling to the hyperbaric chamber. Any subsequent distress
was treated with diazepam (0.1 mg/kg iv every 5 min).

The hyperbaric chamber was a 707.92-liter cylinder (Bethlehem

Steel, Bethlehem, PA), equipped with hull penetrations for physiological and environmental sensor cables and for gas inflow/outflow,
and a platform for insertion of a cart/sling for holding the swine. CO2
accumulated during hyperbaric exposure was removed with a scrubber (CO2 Scrubber 3.80.1080, IHC Hytech). Swine were continuously
monitored by two video cameras situated on viewports outside of the
chamber during hyperbaric exposure.

Monitoring Devices and Data Acquisition

The pulmonary artery catheter was connected to a cardiac output
monitor (Vigilance, Edwards Life Sciences, Irvine, CA) and pulmonary arterial and central venous lines were connected to pressure
transducers (Argon Medical Devices, Athens, TX). However, continuous CO via the pulmonary artery catheter was unreliable (attributed
to the small size of the swine and the fixed position of the thermal
element). Hence CO was monitored by noninvasive cardiac output
(NICOM) and HR was measured by bioreactance (NICOM, Cheetah
Medical, Vancouver, WA). The Mikro-Tip catheter pressure transducer was connected to a blood pressure monitor (Blood pressure
analyzer, Micro-Med, Louisville, KY). Electrocardiogram (ECG)
electrodes (disposable infant/neonatal electrode; Grass/AstroMed,
Warwick, RI) were placed on the shoulders with waveforms generated
by a Cerberus amplifier (Quintlab, Hungary). A pulse oximeter
(Vet/Ox 4404, Heska, Waukesha, WI) sensor was placed on the tail
for use before and after hyperbaric exposure. Additionally, the infusion line was monitored with an ultrasonic flowmeter (T201 Transonic
Systems, Ithaca, NY). Pressure of the diving chamber was measured
with a digital pressure gauge (CPG 2500, Mensor, SanMarcos, TX);
O2 and CO2 concentrations were measured by a gas analyzer (O2/CO2
monitor 9500, Alpha Omega Instrument, Lincoln, RI). Analog waveforms were digitized and recorded on a Dash 32HF (Astro-Med, West
Warwick, RI). Serial data were displayed and recorded directly into a
laptop (Precision M6400, Dell, Round Rock, TX) and a NI USB-232
card (National Instruments, Austin, TX). To calibrate pressure transducers a water column was used with 0 and 136 cm heights (0 and 100
mmHg). For calibrating ECG, 0.5- and 1-mV ECG signals were
generated with a patient simulator (Patient Simulator 214A, Dynatech
Nevada, Carson City, NV) before and after the measurement.

Experimental Protocol
An experimental flow diagram is shown in Fig. 1. Baseline data
were recorded for 30 min after which the intravascular pressure
monitors were disconnected and the swine was inserted into the
hyperbaric chamber. Sensors for ECG and NICOM were reconnected
to through-hull cables to enable continuous monitoring during hyperbaric exposure. The chamber was then compressed to 200 feet of sea
water (fsw) using a nonlinear compression profile described in detail
elsewhere (27). The total time of compression and maintenance at 200
fsw was 31 min; the chamber was then decompressed to atmospheric
pressure at 30 fsw/min. Throughout the hyperbaric exposure, animals
breathed chamber atmosphere air maintained at 21% (0.02%) O2
and a surface equivalent of CO2 0.5% (0.05%).
After reaching surface pressure the swine was removed from the
chamber and reconnected to the pressure transduction cables. The
animal was closely observed for any signs of cutis marmorata (CM),
a morbiliform purple discoloration of the skin that is a form of DCS
(skin bends) and is a predictor for DCS severity in swine (4). Time 0
was defined as CM onset at which time either PFC or normal saline
was infused at 5 ml/kg over 10 min as well as 100% O2 supplied for
60 min using a cone mask (Smith Medical North America, Waukesha,
WI). Animals were observed and data collected for 90 min after CM
onset.
Arterial blood gas samples were collected during the baseline
period and at 30, 60, and 90 min following the CM onset and analyzed
by an ABL 835 blood gas analyzer (Radiometer Copenhagen, Denmark). On completion of the 90-min observation period, ketamine (20
mg/kg iv) was administered, and all sensors, electrodes, and arterial
catheters were removed. The jugular introducer sheath was guide-wire
exchanged for a single-lumen central catheter and sutured into place.
All wounds were closed. A second dose of buprenorphine (0.01 0.1
mg/kg) was administered and the animal was allowed to recover.
After recovery, swine were returned to their holding pens and
observed for any discomfort or paralysis. Any evidence of discomfort
was treated with buprenorphine (0.1 mg/kg im), 23 times daily as
needed. Paralyzed animals were observed at least four times per 24-h
period for interventions that included hand feeding, watering, manual
bladder expression, and repositioning. If their oral intake appeared
inadequate animals were periodically placed in a Panepinto sling for
intravenous fluids. All animals that survived the initial experimental
phase were maintained for 48 h post-hyperbaric exposure.
After completion of the observation period (48 h), animals received
heparin (100 IU/kg; Sagent Pharmaceuticals, Schaumberg, IL) and
were transported to the necropsy suite for humane euthanization with
intravenous Euthasol (11.5 ml/10 lbs; Virbac Animal Health, Fort
Worth, TX). Whole body perfusion fixation was performed (10%
buffered formalin) and the brain and spinal cord were harvested as
well as samples of spleen, kidney, liver, heart, lung, small and large
intestines, and blood. Animals that did not survive to the study end
point (48 h) did not undergo pathological evaluation. Pathology
results are reported separately.
Data Analysis
Data calculations were performed via DataLyser, a locally developed Lab Windows (National Instruments, Austin, TX)-based pro-

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Cardiovascular Parameters in Swine Treated with PFC for DCS

73

Mahon RT et al.

Pressure (fsw)

200
ABG

ABG

ABG

ABG

Events

Infusion (PFC or Saline)

100% FIO2
Surgical
Preparation

Baseline
Monitoring

Hyperbaric
Exposure

Monitoring / Data Collection

Decompression

De-instrumentation
Surgical repair
48-hr observation

Observation &
Reconnection

Timeline

Euthanasia

30

31

6.7

T=0

+30

+60

+90

DCS
Diagnosis

Time (minutes)
Fig. 1. Schematic of experimental procedures and timeline with pressure exposure in feet of sea water (fsw). ABG, arterial blood gas; DCS, decompression
sickness.

gram or via MATLAB (The Mathworks, Natick, MA); statistical

analyses were performed using either Excel or MATLAB. Group
values for animal weight, time of DCS onset, time of maximum PAP
elevation, and means of cardiovascular parameters were statistically
compared using a t-test. In addition to the above groups, PFC
irrespective of sex was compared with saline control, and males
irrespective of treatment were compared with females.
Data points were extracted from analog data at 30-s intervals and a
moving 10-min interval mean (20 data points) was calculated in
MATLAB for each group. Setting time of DCS onset as time 0, 90
min of moving means were grouped into nine 10-min intervals for
ANOVA analysis using Excel.
Mean values of blood gas data (pH, PCO2, PO2, and lactate concentration), collected at baseline and at 30, 60, and 90 min after DCS
onset were compared using a t-test for two-group comparisons, and
ANOVA for four-group comparisons.

not significantly different when comparing all animals randomized to PFC to all animals randomize to saline (10.48 vs. 8.28
min post-surfacing, P 0.24). DCS onset was quicker in
females than males (7.30 vs. 11.46 min post-surfacing, P
0.02). Mean CO, PAP, SAP, and HR were elevated in all
groups during the period between reaching surface pressure
and DCS onset. These post-surfacing preonset elevations were
all statistically significant (P 0.05) compared with group
mean baselines except for CO in males randomized to PFC
treatment and HR in females randomized to PFC treatment
(Table 2, Fig. 2).
Hemodynamics Throughout the 90-min Observation Period
When the 90-min post-DCS observation period was taken as
a whole, CO and PAP were significantly elevated in the PFC

RESULTS

General
There were no significant weight differences between
groups. However, there was significant variability in baseline
cardiovascular parameters among the four treatment/sex
groups (Table 1).
DCS Onset
All animals developed CM and were diagnosed with DCS.
Prior to any treatment initiation, time to CM (DCS onset) was

Table 1. Baseline cardiovascular characteristic comparisons

using one-way ANOVA (n 8 per group)
Group

PAP, mmHg

CO, l/min

HR, beats/min

SAP, mmHg

PFC/female
PFC/male
Saline/female
Saline/male
P value

18.21
19.50
20.51
23.07
0.05

8.78
4.62
6.00
6.85
0.05

125.24
177.37
136.53
137.04
0.05

111.43
102.06
113.72
109.37
0.05

PAP, pulmonary artery pressure; CO, cardiac output; HR, heart rate; SAP,
systemic arterial pressure; PFC, perfluorocarbons.

J Appl Physiol doi:10.1152/japplphysiol.00727.2014 www.jappl.org

Cardiovascular Parameters in Swine Treated with PFC for DCS

Table 2. Comparing post-DCS onset, 90-min observation

periods of PFC to saline and female to male hemodynamics
data

vs. male

Cardiac Output
(% Baseline)

7.26
6.89
0.05

110
105
100
95
90
85
80

120
100
80

160

150

140

130

120

110

100

FPC/Female
PFC/Male
Saline/Female
Saline/Male

150
140
130
120
110
100
90
80
70

J Appl Physiol doi:10.1152/japplphysiol.00727.2014 www.jappl.org

0
.59
80

70

80
.570

60

.560

.5-

Time (minutes)

50

.55
40

.5-

50

40

60

30

Fig. 2. Graph of cardiac output, pulmonary artery pressure, systemic arterial

pressure (SAP), and heart rate in each group as normalized to percentage of
baseline. Baseline values denoted by BL, end of 31-min hyperbaric (HB)
exposure denoted by first vertical line, variable time interval between end of
exposure and DCS onset denoted by second vertical line, with the onset of
DCS noted at time 0 with second vertical dotted line.

140

Although this study was not powered to detect survival

differences, survival to 90 min and to 48 h were not statistically
different between swine treated with PFC compared with
saline-treated controls (75% vs. 88%, P 0.16; and 63% vs.
81%, P 0.08, respectively). Similarly, there was no statistically significant difference in incidence of paralysis between
PFC- and saline-treated swine (25% vs. 19%, P 0.33) and no
statistically significant differences in survival at the 90-min
postexposure or 48-h end points across the four groups: saline
male (88%, 75%), saline female (88%, 75%), PFC male (75%,
63%), and PFC female (75%, 63%). Finally, there was no
statistically significant difference in incidence of paralysis

160

.53

Morbidity and mortality

180

.52

treatment group (male and female combined); SAP was not

significantly different, and HR was significantly elevated in the
saline group (male and female combined). Females (treatment
and control combined) exhibited higher CO, no difference in
PAP or SAP, and a lower HR compared with the males
(treatment and control combined). This latter difference was
most pronounced when considering a markedly elevated HR in
the saline control males (Table 2, Fig. 2).
Mean time to peak PAP was not significantly different
between the PFC- and saline-treated groups (8.75 and 7.07 min
post-CM onset, respectively). In both PFC- and saline-treated
females, peak PAP was reached sooner than in their male
counterparts (6.41 and 9.69 min post-CM onset, respectively;
P 0.0069). However, the peak PAP values were not significantly different (Table 3).

200

20

DCS, decompression sickness.

220

10

vs. male

127.22
122.01
0.05

240

nse
t
0-1
0

vs. male

75

126.98
168.33
0.05

SO

PFC mean
Saline mean
P value: PFC vs. saline

vs. male

29.32
29.83
0.05

BL
En
Ex d HB
po
sur
e

PFC mean
Saline mean
P value: PFC vs. saline

PAP, mmHg
33.41
Female mean
25.78
Male mean
0.05
P value: female
CO, l/min
7.20
Female mean
6.95
Male mean
0.05
P value: female
HR, beats/min
124.52
Female mean
170.51
Male mean
0.05
P value: female
SAP, mmHg
124.54
Female mean
124.72
Male mean
0.05
P value: female

115

Pulmonary Artery Pressure

(% Baseline)

PFC mean
Saline mean
P value: PFC vs. saline

120

Sex Effects

SAP (% Baseline)

PFC mean
Saline mean
P value: PFC vs. saline

Mahon RT et al.

125

Heart Rate (% Baseline)

Treatment Effects

DC

74

Cardiovascular Parameters in Swine Treated with PFC for DCS

75

Mahon RT et al.

Table 3. Comparison of time to peak PAP and PAP measurement after CM onset and treatment for DCS (concurrent)
Males

Females

Combined Sexes

Treatment

Peak PAP, mmHg

Time to peak PAP, min

Peak PAP, mmHg

Time to peak PAP, min

Peak PAP, mmHg

Time to peak PAP, min

Oxycyte
Saline
Combined treatments

45.95
33.73
39.37

12.08
7.64
9.69

44.33
43.30
43.82

6.25
6.56
6.41*

45.02
38.83

8.75
7.07

CM, cutis marmorata. *Significantly different from corresponding males at P 0.05 level.

among the four groups: saline male (13%), saline female

(25%), PFC male (25%), and PFC female (25%).
Normalized Data
Sex difference hemodynamics due to DCS. The baseline
differences in CO and PAP led us to compare changes in group
means normalized to baseline. Comparing percentage changes
of group mean values for males vs. females treated only with
saline, DCS onset coincides with a significant difference in
HR, with female values remaining at or near baseline and male
values being elevated. Cardiac outputs were initially elevated
in both males and females postsurfacing, but then dropped to
near baseline in males and below baseline in females. Mean
PAP increased in both males and females, but more so in
females. Mean SAP also increased in both males and females,
but in this case more so in males (Table 4, time period 0 10,
and Fig. 2).
Male vs. female: within-treatment sex comparisons. Among
the saline-treated controls, females exhibited lower CO
throughout, and elevated PAP during the initial 70 min of
observation compared with saline-treated males. Control males
and females both demonstrated an increased SAP; however,
the increase in females was less robust than their male counterparts (Fig. 2, Table 4).
Among PFC-treated swine, CO, PAP, and SAP were significantly increased in females compared with males during the
initial 10-min observation interval. CO in the females decreased below male values after 30 min. PAP in females was

lower than in males in the 20- to 40-min interval, although it

was elevated above baseline in both groups for the entire
90-min observation period. SAP remained elevated in all time
periods in PFC-treated females compared to PFC treated males
(Fig. 2, Table 5).
PFC vs. saline treatment comparisons. Among females,
PFC-treatment significantly increased CO in the initial period
after DCS onset, followed after 30 min by a lower CO than
observed in the saline group. PAP in PFC-treated females was
below that seen in the saline group in the initial period, but
remained persistently elevated after 40 min. SAP remained
elevated above baseline in the PFC-treated female group during the full post-hyperbaric exposure period (Fig. 2, Table 6).
Among males, treatment with PFC produced a lower CO and
HR and higher PAP throughout the 90-min observation period
compared with male/saline controls. Male/saline controls had a
significantly elevated PAP following onset of DCS but returned to
baseline by 70 min. However, unlike PFC-treated females, the
SAP for both PFC-treated and saline-treated males showed only a
transient initial elevation that was not present during the majority
of the 90-min observation period (Fig. 2, Table 7).
Arterial blood gas and lactic acid level measurements at
baseline and during the 90-min observation period showed no
significant differences except for pH at 90 min.
DISCUSSION

In this study we aimed to evaluate any significant differences

in cardiovascular parameters with severe DCS between sexes

Table 4. Effect of sex differences in 10-min intervals between female swine injected with saline vs. male swine injected with
saline using data normalized to baseline
Time Period, min
010

10.520

20.530

Sal/F mean
Sal/M mean
P value

206.13
155.34
0.05

221.71
165.89
0.05

214.30
168.57
0.05

Sal/F mean
Sal/M mean
P value

86.49
97.03
0.05

88.82
101.71
0.05

99.29
105.87
0.05

Sal/F mean
Sal/M mean
P value

94.01
123.89
0.05

91.51
123.81
0.05

93.03
128.57
0.05

Sal/F mean
Sal/M mean
P value

126.05
134.35
0.05

122.93
132.09
0.05

112.92
123.93
0.05

30.540

40.550

PAP, mmHg
173.25
151.40
143.68
131.59
0.05
0.05
CO, l/min
109.95
102.74
111.26
111.12
0.05
0.05
HR, beats/min
98.50
100.57
134.98
130.37
0.05
0.05
SAP, mmHg
106.77
104.93
112.95
112.82
0.05
0.05

50.560

60.570

70.580

80.590

127.69
122.79
0.05

116.51
107.65
0.05

104.29
109.20
0.05

107.06
115.22
0.05

98.41
107.61
0.05

95.77
111.46
0.05

86.70
106.59
0.05

81.23
99.52
0.05

101.36
127.33
0.05

100.76
134.37
0.05

99.55
141.02
0.05

100.23
146.31
0.05

105.27
112.76
0.05

105.90
113.28
0.05

106.84
113.65
0.05

107.11
113.06
0.05

Sal, saline; F, female; M, male.

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76

Cardiovascular Parameters in Swine Treated with PFC for DCS

Mahon RT et al.

Table 5. Effect of female vs. male swine injected with PFC in 10-min intervals after DCS onset using data normalized to
baseline
Time Period, min
010

10.520

20.530

PFC/F mean
PFC/M mean
P value

204.43
192.64
0.05

197.89
199.75
NS

180.36
206.05
0.05

PFC/F mean
PFC/M mean
P value

106.60
87.22
0.05

101.07
87.54
0.05

104.34
94.04
0.05

PFC/F mean
PFC/M mean
P value

102.05
83.92
0.05

88.73
86.31
0.05

82.17
93.64
0.05

PFC/F mean
PFC/M mean
P value

159.19
129.66
0.05

146.19
123.07
0.05

139.99
111.36
0.05

30.540

40.550

PAP, mmHg
165.19
164.38
176.98
157.51
0.05
0.05
CO, l/min
94.99
89.34
101.57
98.91
0.05
0.05
HR, beats/min
85.09
85.48
86.33
83.23
0.05
0.05
SAP, mmHg
130.20
125.65
108.80
108.28
0.05
0.05

50.560

60.570

70.580

80.590

163.53
158.02
0.05

167.78
158.21
0.05

194.01
171.97
0.05

196.30
180.09
0.05

91.42
91.17
0.05

87.68
91.55
0.05

83.61
91.83
0.05

79.13
88.43
0.05

86.85
80.45
0.05

90.83
81.22
0.05

95.36
90.28
0.05

N/A

121.91
108.76
0.05

120.90
109.14
0.05

124.03
106.47
0.05

123.18
N/A

NS, not significant.

in a swine model treated with emulsified PFC. Significant

differences were noted between sexes regarding the rapidity of
DCS onset as well as several cardiovascular parameters with
and without PFC treatment.
Although sex differences in DCS have been hypothesized
for several years, no conclusive evidence has been demonstrated. Hypothetically, human females may be at greater risk
of DCS due to relatively higher body fat relative to males.
Differences in nitrogen absorption have been hypothesized and
differences in nitrogen elimination between sexes have been
demonstrated (6, 22, 30). Hart and Strauss (18) also demonstrated via in vivo gas measurements on human volunteers that
females release subcutaneous N2 more slowly than males,
although values for muscle were similar. They theorized that
this difference in N2 release was due to differences in tissue
perfusion, although no correction for body fat content was

mentioned. With a prospective study of altitude DCS, Webb et

al. (40) demonstrated that it was body mass index and maximal
oxygen consumption (but not sex) that correlated with actual
DCS risk. Interestingly, they showed that females on hormonal
contraceptives were at higher risk for DCS in the last 2 wk of
their menstrual cycle than those not on such therapy. In our
study no attempt was made to determine the hormonal milieu
of the swine.
Although mixed-sex animal studies have been performed, a
literature search found none that were designed explicitly to
evaluate sex differences in animal models of DCS. In this
report females had a quicker DCS onset compared with males.
The significantly earlier DCS onset seen in females was not
associated with any obvious differences in hemodynamics immediately preceding DCS; all groups showed an increase in CO,
SAP, and PAP in the period immediately preceding the onset of

Table 6. Effect of PFC vs. saline in 10-min intervals in female swine using data normalized to baseline
Time Period, min
010

10.520

20.530

PFC/F mean
Sal/F mean
P value

204.43
206.13
NS

197.89
221.71
0.05

180.36
214.30
0.05

PFC/F mean
Sal/F mean
P value

106.60
86.49
0.05

101.07
88.82
0.05

104.34
99.29
0.05

PFC/F mean
Sal/F mean
P value

102.05
94.01
0.05

88.73
91.51
0.05

82.17
93.03
0.05

PFC/F mean
Sal/F mean
P value

159.19
126.05
0.05

146.19
122.93
0.05

139.99
112.92
0.05

30.540

40.550

PAP, mmHg
165.19
164.38
173.25
151.40
0.05
0.05
CO, l/min
94.99
89.34
109.95
102.74
0.05
0.05
HR, beats/min
85.09
85.48
98.50
100.57
0.05
0.05
SAP, mmHg
130.20
125.65
106.77
104.93
0.05
0.05

50.560

60.570

70.580

80.590

163.53
127.69
0.05

167.78
116.51
0.05

194.01
104.29
0.05

196.30
107.06
0.05

91.42
98.41
0.05

87.68
95.77
0.05

83.61
86.70
0.05

79.13
81.23
0.05

86.85
101.36
0.05

90.83
100.76
0.05

95.36
99.55
0.05

100.23
N/A

121.91
105.27
0.05

120.90
105.90
0.05

124.03
106.84
0.05

123.18
107.11
0.05

N/A, not available.

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Cardiovascular Parameters in Swine Treated with PFC for DCS

77

Mahon RT et al.

Table 7. Effect of PFC vs. saline therapy in 10-min intervals on male swine using data normalized to baseline
Time Period, min
010

10.520

20.530

PFC/M mean
Sal/M mean
P value

192.64
155.34
0.05

199.75
165.89
0.05

206.05
168.57
0.05

PFC/M mean
Sal/M mean
P value

87.22
97.03
0.05

87.54
101.71
0.05

94.04
105.87
0.05

PFC/M mean
Sal/M mean
P value

83.92
123.89
0.05

86.31
123.81
0.05

93.64
128.57
0.05

PFC/M mean
Sal/M mean
P value

129.66
134.35
0.05

123.07
132.09
0.05

111.36
123.93
0.05

30.540

40.550

PAP, mmHg
176.98
157.51
143.68
131.59
0.05
0.05
CO, l/min
101.57
98.91
111.26
111.12
0.05
0.05
HR, beats/min
86.33
83.23
134.98
130.37
0.05
0.05
SAP, mmHg
108.80
108.28
112.95
112.82
0.05
0.05

DCS. However, after the onset of DCS all females demonstrated

an earlier time to peak PAP compared with males.
The effect of PFC between sexes was less clear-cut. All
PFC-treated animals exhibited an increase in PAP throughout
the full 90-min observation period. With respect to sex, PFCtreated females compared with female controls exhibited a
relatively higher CO and lower PAP in the initial post-DCS
period, but 30 min into the 90-min observation period this
reversed to relatively decreased CO and persistently elevated
PAP. Among controls data suggest that female swine had more
cardiovascular compromise with DCS (controls with higher
PAP and SAP and lower CO than males). PFC-treated females
had a more favorable initial cardiovascular response but more
deranged cardiovascular findings later, with persistently elevated PAP and decreased CO.
PFC-treated males compared with male controls were likewise interesting. Taken as a whole, PAP was elevated in PFC
treated males and CO was decreased during the full 90-min
observation period. Initially, SAP increased in the both control
and PFC males but then decreased in the PFC-treated group
after the initial 10-min interval, returning near baseline. Although such a pattern of increased PAP and decreased CO and
SAP raises concern about right heart failure (20), mortality
between the male PFC and control groups in this study was not
significantly different.
Elevated PAP with DCS has been described in other PFC
studies using swine and sheep (32, 35). In animal models, an
elevated PAP with severe DCS and venous gas embolism has
been correlated with increased bubble counts (5, 7, 38). This is
consistent with capillary obstruction by bubbles as the mechanism, but is also consistent with increased vasoreactivity
secondary to bubble endothelial interaction as the cause (23).
With evidence that all PFC-treated animals had a higher
PAP during the 90-min observation period, concern for the
effect(s) of emulsified PFC is heightened. Contrary to our
results, Spiess et al. (35) showed no difference in PAP with
PFC treatment of severe DCS. However, that study differed
from ours in that PFC was infused before DCS onset and PAP
rise was reported at discreet 15-min time points. In line with
the swine data reported here, it appears that sheep with severe

50.560

60.570

70.580

80.590

158.02
122.79
0.05

158.21
107.65
0.05

171.97
109.20
0.05

180.09
115.22
0.05

91.17
107.61
0.05

91.55
111.46
0.05

91.83
106.59
0.05

88.43
99.52
0.05

80.45
127.33
0.05

81.22
134.37
0.05

90.28
141.02
0.05

146.31
N/A

108.76
112.76
0.05

109.14
113.28
0.05

106.47
113.65
0.05

113.06
N/A

DCS also demonstrate evidence of further elevation in PAP

with PFC therapy (32).
An elevated PAP in Artiadactyla (swine, sheep, goats, etc.)
without DCS has been described with PFC emulsions and has
been attributed to a similarly transient PAP rise with other
small particulate injections (14). Small particle liposomes were
demonstrated to cause a transient increase in PAP that correlated with liposome retention in the lung and pulmonary
macrophages (29). This rise was correlated with marked rise in
systemic levels of TXB2 (metabolite of thromboxane). Inhibitors of the arachidonic acid pathway appear to block this
response. Although intrapulmonary macrophages were hypothesized as the source of the TXB2, the authors (admittedly) did
not confirm this. Szebeni et al. (36) subsequently demonstrated
that complement activation appeared to play a significant role
in this reaction; liposome size and composition had a strong
influence on the degree of PAP with large (0.35 m) multilamellar compounds causing a robust rise in PAP, and small
(0.19 m) unilamellar compounds having little or no effect
on PAP. This so-called complement activation pseudoallergy
(CARPA) with liposomes was reproduced in a swine model
using human C3a and C5a administration. Of note, CARPA
has been described in several species to include the Artiadactyla, canines, rats, as well as humans.
Most emulsified PFC compounds are lipid particles, with a
median particle size of 0.2 0.25 m (however with some
particles up to 0.6 m) and hence within a particle size range
where elevated PAP would potentially be anticipated (34, 36).
Although there is no evidence of elevated PAP in humans who
have received Oxycyte, elevated PAP was reported in a patient
receiving an infusion of an older-generation PFC (Fluosol)
(37). Further complicating matters, the dynamics of PFC lipid
particles in the face of intravascular bubbles is essentially
unknown and conceivably may alter the biologic particle size
or activity.
Despite evidence of adverse hemodynamic effects of PFC
emulsion in swine (and sheep), PFCs have a long history in the
prevention of DCS as well as improving mortality after DCS
onset in animal models (9, 27). This improvement could be due
to overall higher oxygen content, enhanced nitrogen elimina-

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78

Cardiovascular Parameters in Swine Treated with PFC for DCS

tion, or surfactant properties that may limit arterial bubble

derangements (12, 13, 26, 31, 32).
Why female swine manifested earlier onset and less time to
peak PAP can only be hypothesized. Possible explanations
include differences in body composition, hormonal milieu, or
vascular anatomic differences. Additionally, we did not evaluate any differences in skin composition to include adipose
vascular supply as the cause for the earlier onset of CM.
Likewise, the basis for groups demonstrating differences in
PAP and CO at baseline is unknown. Certainly some of the
differences, such as a PAP difference of 4 mmHg among
groups, would not be surprising and reflects the small standard
deviations from analysis of intervals. As PAP was our primary
interest we are satisfied with these statistically, but relatively
minor, differences at baseline. However, the larger differences
seen at baseline CO may be clinically relevant. We cannot
exclude differences in anesthetic and sedative effects between
sexes. Although not presented here, we observed no differences in body temperature or level of hemoglobin, both factors
that can affect CO.
Our study is not without flaw, the most significant being the
entirely noninvasive measurement of CO. Unfortunately, the
pulmonary artery catheter for continuous CO was unreliable in
this small swine model. Although originally designed to serve
as our gold standard, the small swine size did not allow for
proper positioning of the thermal element. The bioreactancebased noninvasive CO measurement we used is based on an
analysis of relative phase shifts of an oscillating current that
occur when this current traverses the thoracic cavity, as opposed to traditional bioimpedance-based systems, which rely
only on measured changes in signal amplitude. Noninvasive
CO monitoring using similar bioimpedance has shown reliable
measurements when compared with oxygen consumption
(Fick) techniques and demonstrated a high correlation in a
swine model using cardiopulmonary bypass to regulate CO
(21, 24). Comparing gold-standard CO measurements with
the bioreactance measurement of NICOM has been useful in
predicting fluid responsiveness in patients with shock and
shorter hospital stays in trauma patients (10, 28). Admittedly,
we find no studies involving NICOM CO measurements in
DCS and, as is the case with other invasive and noninvasive
techniques, its use has not been validated in DCS.
Conclusions
Female swine appear to have earlier DCS onset and more
severe hemodynamic manifestations (as judged by PAP) compared with male swine. Oxycyte was associated with a higher
PAP in both sexes with severe DCS. Further study into the
mechanisms of these findings should be examined before
considering human studies with Oxycyte in DCS.
ACKNOWLEDGMENTS
We thank C. Whittier and W. Koller for technical support, and L. Baranyi
for use of the DataLyser.
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 U.S. Government. This work was prepared as
a part of officials duties. Title 17 USC provides that Copyright protection is not
available for any work of the United States Government, defined as work
prepared by a military service member of employee of the U.S. Government as
part of their official duties.

Mahon RT et al.

GRANTS
This work was funded by The Office of Naval Research through work unit
0603713N.0000.000.A0902.
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared by the author(s).
AUTHOR CONTRIBUTIONS
Author contributions: R.T.M. and C.R.A. conception and design of research; R.T.M., W.A.C., and M.B. performed experiments; R.T.M., M.B., and
S.T. analyzed data; R.T.M. interpreted results of experiments; R.T.M. and
C.R.A. drafted manuscript; R.T.M. approved final version of manuscript;
W.A.C., D.P.R., and C.R.A. edited and revised manuscript; S.T. and C.R.A.
prepared figures.
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