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Cassignol A, Marmin J, Mattei P, Goffinet L, Pons S, Renard A, Demory D, Bordes J. Civilian prehospital transfusion - experiences from a French region. Vox Sang 2020; 115:745-755. [PMID: 32895933 DOI: 10.1111/vox.12984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/23/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Haemorrhagic shock is a leading cause of avoidable mortality in prehospital care. For several years, our centre has followed a procedure of transfusing two units of packed red blood cells outside the hospital. Our study's aim was twofold: describe the patient characteristics of those receiving prehospital blood transfusions and analyse risk factors for the 7-day mortality rate. MATERIALS AND METHODS We performed a monocentric retrospective observational study. Demographic and physiological data were recovered from medical records. The primary outcome was mortality at seven days for all causes. All patients receiving prehospital blood transfusions between 2013 and 2018 were included. RESULTS Out of 116 eligible patients, 56 patients received transfusions. Trauma patients (n = 18) were younger than medical patients (n = 38) (P = 0·012), had lower systolic blood pressure (P = 0·001) and had higher haemoglobin levels (P = 0·016). Mortality was higher in the trauma group than the medical group (P = 0·015). In-hospital trauma patients received more fresh-frozen plasma and platelet concentrate than medical patients (P < 0·05). Predictive factors of 7-day mortality included transfusion for trauma-related reasons, low Glasgow Coma Scale, low peripheral oxygen saturation, prehospital intensive resuscitation, existing coagulation disorders, acidosis and hyperlactataemia (P < 0·05). CONCLUSION Current guidelines recommend early transfusion in patients with haemorrhagic shock. Prehospital blood transfusions are safe. Coagulation disorders and acidosis remain a cause of premature death in patients with prehospital transfusions.
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Affiliation(s)
- Arnaud Cassignol
- SMUR Department, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Julien Marmin
- SMUR Department, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Pascal Mattei
- SMUR Department, Sainte-Musse Public Hospital, Toulon, France
| | - Léa Goffinet
- French Blood Establishment, Sainte-Musse Public Hospital, Toulon, France
| | - Sandrine Pons
- French Blood Establishment, Sainte-Anne Military Hospital, Toulon, France
| | - Aurélien Renard
- Emergency Department, Sainte-Anne Military Hospital, Toulon, France
| | - Didier Demory
- Clinical Research Unit, Sainte-Musse Public Hospital, Toulon, France
| | - Julien Bordes
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, Toulon, France
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Williams AT, Lucas A, Muller CR, Bolden-Rush C, Palmer AF, Cabrales P. Balance between oxygen transport and blood rheology during resuscitation from hemorrhagic shock with polymerized bovine hemoglobin. J Appl Physiol (1985) 2020; 129:97-107. [PMID: 32552431 DOI: 10.1152/japplphysiol.00016.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Alternatives to blood for use in transfusion medicine have been investigated for decades. An ideal alternative should improve oxygen (O2)-carrying capacity and O2 delivery and support microvascular blood flow. Previous studies have shown that large-molecular diameter hemoglobin (Hb)-based oxygen carriers (HBOCs) based on polymerized bovine Hb (PolybHb) reduce the toxicity and vasoconstriction of first-generation HBOCs by increasing blood and plasma viscosity and preserving microvascular perfusion. The objective of this study was to examine the impact of PolybHb concentration and therefore O2-carrying capacity and solution viscosity on resuscitation from hemorrhagic shock in rats. PolybHb was diafiltered on a 500-kDa tangential flow filtration (TFF) module to remove low-molecular weight (MW) PolybHb molecules from the final product. Rats were hemorrhaged and maintained in hypovolemic shock for 30 min before transfusion of PolybHb at 10 g/dL (PHB10), 5 g/dL (PHB5), or 2.5 g/dL (PHB2.5) concentration, to restore blood pressure to 90% of the animal's baseline blood pressure. Resuscitation restored blood pressure and cardiac function in a PolybHb concentration-dependent manner. Parameters indicative of the heart's metabolic activity indicated that the two higher PolybHb concentrations better restored coronary O2 delivery compared with the low concentration evaluated. Markers of organ damage and inflammation were highest for PHB10, whereas PHB5 and PHB2.5 showed similar expression of these markers. These studies indicate that a concentration of ~5 g/dL of PolybHb may be near the optimal concentration to restore cardiac function, preserve organ function, and mitigate the toxicity of PolybHb during resuscitation from hemorrhagic shock.NEW & NOTEWORTHY Large-molecular diameter polymerized bovine hemoglobin avoided vasoconstriction and impairment of cardiac function during resuscitation from hemorrhagic shock that was seen with previous hemoglobin-based O2 carriers by increasing blood viscosity in a concentration-dependent manner. Supplementation of O2-carrying capacity played a smaller role in maintaining cardiac function than increased blood and plasma viscosity.
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Affiliation(s)
- Alexander T Williams
- Department of Bioengineering, University of California, San Diego, La Jolla, California
| | - Alfredo Lucas
- Department of Bioengineering, University of California, San Diego, La Jolla, California
| | - Cynthia R Muller
- Department of Bioengineering, University of California, San Diego, La Jolla, California
| | - Crystal Bolden-Rush
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio
| | - Andre F Palmer
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio
| | - Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, La Jolla, California
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Uchida K, Nishimura T, Hagawa N, Kaga S, Noda T, Shinyama N, Yamamoto H, Mizobata Y. The impact of early administration of vasopressor agents for the resuscitation of severe hemorrhagic shock following blunt trauma. BMC Emerg Med 2020; 20:26. [PMID: 32299385 PMCID: PMC7164243 DOI: 10.1186/s12873-020-00322-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/08/2020] [Indexed: 02/06/2023] Open
Abstract
Background When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. Methods In this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival < 0.6. Vital signs on arrival, characteristics, examinations, concomitant injuries and severity, vasopressor use and dose, and volumes of crystalloids and blood infused were compared between survivors and non-survivors. Data are described as median (25–75% interquartile range) or number. Results Forty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36–48) vs 45 (34–51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12–0.48] vs 0.21 [0.08–0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680–9320] vs 6540 [4550–7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0–4] vs 14 [10–18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4–26] vs 34 [10–74] hours; p = 0.026) in survivors. Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71–121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90–58.5; p = 0.005) indicated significant higher risk of death in this study. Conclusion Vasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.
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Affiliation(s)
- Kenichiro Uchida
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan.
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Naohiro Hagawa
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Shinichiro Kaga
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Tomohiro Noda
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Naoki Shinyama
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Hiromasa Yamamoto
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine, Osaka City University, Graduate school of medicine, , 1-5-7, Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
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Effect of Polyethylene-glycolated Carboxyhemoglobin on Renal Microcirculation in a Rat Model of Hemorrhagic Shock. Anesthesiology 2020; 131:1110-1124. [PMID: 31490291 DOI: 10.1097/aln.0000000000002932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Primary resuscitation fluid to treat hemorrhagic shock remains controversial. Use of hydroxyethyl starches raised concerns of acute kidney injury. Polyethylene-glycolated carboxyhemoglobin, which has carbon monoxide-releasing molecules and oxygen-carrying properties, was hypothesized to sustain cortical renal microcirculatory PO2 after hemorrhagic shock and reduce kidney injury. METHODS Anesthetized and ventilated rats (n = 42) were subjected to pressure-controlled hemorrhagic shock for 1 h. Renal cortical PO2 was measured in exposed kidneys using a phosphorescence quenching method. Rats were randomly assigned to six groups: polyethylene-glycolated carboxyhemoglobin 320 mg · kg, 6% hydroxyethyl starch (130/0.4) in Ringer's acetate, blood retransfusion, diluted blood retransfusion (~4 g · dl), nonresuscitated animals, and time control. Nitric oxide and heme oxygenase 1 levels were determined in plasma. Kidney immunohistochemistry (histologic scores of neutrophil gelatinase-associated lipocalin and tumor necrosis factor-α) and tubular histologic damages analyses were performed. RESULTS Blood and diluted blood restored renal PO2 to 51 ± 5 mmHg (mean difference, -18; 95% CI, -26 to -11; P < 0.0001) and 47 ± 5 mmHg (mean difference, -23; 95% CI, -31 to -15; P < 0.0001), respectively, compared with 29 ± 8 mmHg for hydroxyethyl starch. No differences between polyethylene-glycolated carboxyhemoglobin and hydroxyethyl starch were observed (33 ± 7 mmHg vs. 29 ± 8 mmHg; mean difference, -5; 95% CI, -12 to 3; P = 0.387), but significantly less volume was administered (4.5 [3.3-6.2] vs. 8.5[7.7-11.4] ml; mean rank difference, 11.98; P = 0.387). Blood and diluted blood increased the plasma bioavailability of nitric oxide compared with hydroxyethyl starch (mean rank difference, -20.97; P = 0.004; and -17.13; P = 0.029, respectively). No changes in heme oxygenase 1 levels were observed. Polyethylene-glycolated carboxyhemoglobin limited tubular histologic damages compared with hydroxyethyl starch (mean rank difference, 60.12; P = 0.0012) with reduced neutrophil gelatinase-associated lipocalin (mean rank difference, 84.43; P < 0.0001) and tumor necrosis factor-α (mean rank difference, 49.67; P = 0.026) histologic scores. CONCLUSIONS Polyethylene-glycolated carboxyhemoglobin resuscitation did not improve renal PO2 but limited tubular histologic damages and neutrophil gelatinase-associated lipocalin upregulation after hemorrhage compared with hydroxyethyl starch, whereas a lower volume was required to sustain macrocirculation.
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Attenuation of Multiple Organ Damage by Continuous Low-Dose Solvent-Free Infusions of Resveratrol after Severe Hemorrhagic Shock in Rats. Nutrients 2017; 9:nu9080889. [PMID: 28817064 PMCID: PMC5579682 DOI: 10.3390/nu9080889] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/11/2017] [Accepted: 08/14/2017] [Indexed: 01/05/2023] Open
Abstract
Therapeutic effects of continuous intravenous infusions of solvent-free low doses of resveratrol on organ injury and systemic consequences resulting from severe hemorrhagic shock in rats were studied. Hemorrhagic shock was induced by withdrawing arterial blood until a mean arterial blood pressure (MAP) of 25-30 mmHg was reached. Following a shock phase of 60 min, rats were resuscitated with the withdrawn blood plus lactated Ringer's. Resveratrol (20 or 60 μg/kg × h) was continuously infused intravenously starting with the resuscitation phase (30 min) and continued until the end of the experiment (total treatment time 180 min). Animals of the shock control group received 0.9% NaCl solution. After the observation phase (150 min), rats were sacrificed. Resveratrol significantly stabilized the MAP and peripheral oxygen saturation after hemorrhagic shock, decreased the macroscopic injury of the small intestine, significantly attenuated the shock-induced increase in tissue myeloperoxidase activity in the small intestine, liver, kidney and lung, and diminished tissue hemorrhages (particularly in the small intestine and liver) as well as the rate of hemolysis. Already very low doses of resveratrol, continuously infused during resuscitation after severe hemorrhagic shock, can significantly improve impaired systemic parameters and attenuate multiple organ damage in rats.
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Dretzke J, Burls A, Bayliss S, Sandercock J. The clinical effectiveness of pre-hospital intravenous fluid replacement in trauma patients without head injury: a systematic review. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408606071972] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traditionally, the management of bleeding trauma patients has included early rapid fluid replacement on scene. However, evidence shows that a delay to definitive treatment (control of bleeding) may be harmful and UK policy advocates minimal delay on scene with intravenous fluids being administered in transit to hospitals. This paper systematically reviews the evidence for administering fluids in pre-hospital trauma patients with no head injury. Randomized controlled trials comparing immediate and delayed fluid replacement were sought using formal search strategies. Study selection, quality assessment and data extraction were performed independently by two reviewers using pre-defined criteria. We found no evidence to suggest that pre-hospital fluid administration is beneficial. There is some evidence that it may be harmful and that patients do comparatively well when fluids are withheld. However, this evidence is not conclusive, particularly for blunt trauma, and is not sufficient to disprove current UK policy, which recommends hypotensive resuscitation.
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Affiliation(s)
- Janine Dretzke
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK,
| | - Amanda Burls
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
| | - Sue Bayliss
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
| | - Josie Sandercock
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
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7
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L-Malate's Plasma and Excretion Profile in the Treatment of Moderate and Severe Hemorrhagic Shock in Rats. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5237148. [PMID: 27403429 PMCID: PMC4925959 DOI: 10.1155/2016/5237148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/27/2016] [Accepted: 06/01/2016] [Indexed: 01/04/2023]
Abstract
Introduction. Malate is a standard component in fluid therapy within a wide range of medical applications. To date, there are insufficient data regarding its plasma distribution, renal excretion, and metabolism after infusion. This study aimed to investigate these three aspects in a rat model of moderate and severe hemorrhagic shock (HS). Methods. Male Wistar rats were subjected to HS by dropping the mean arterial blood pressure to 25-30 mmHg (severe) and 40-45 mmHg (moderate), respectively, for 60 minutes. Subsequently, reperfusion with Ringer-saline or a malate containing crystalloid solution (7 mM, 13.6 mM, and 21 mM, resp.) was performed within 30 minutes, followed by an observation period of 150 minutes. Results. In the present experiments, malate rapidly disappeared from the blood, while only 5% of the infused malate was renally excreted. In the resuscitation interval the urinary citrate and succinate amounts significantly increased compared to control. Conclusion. Malate's half-life is between 30 and 60 minutes in both, moderate and severe HS. Thus, even under traumatic conditions malate seems to be subjected to rapid metabolism with participation of the kidneys.
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Chatrath V, Khetarpal R, Ahuja J. Fluid management in patients with trauma: Restrictive versus liberal approach. J Anaesthesiol Clin Pharmacol 2015; 31:308-16. [PMID: 26330707 PMCID: PMC4541175 DOI: 10.4103/0970-9185.161664] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.
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Affiliation(s)
- Veena Chatrath
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Ranjana Khetarpal
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
| | - Jogesh Ahuja
- Department of Anaesthesia and Critical Care, Government Medical College, Amritsar, Punjab, India
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Comparison of Malated Ringer's with Two Other Balanced Crystalloid Solutions in Resuscitation of Both Severe and Moderate Hemorrhagic Shock in Rats. BIOMED RESEARCH INTERNATIONAL 2015; 2015:151503. [PMID: 26106600 PMCID: PMC4461728 DOI: 10.1155/2015/151503] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/11/2015] [Accepted: 05/12/2015] [Indexed: 01/25/2023]
Abstract
In preclinical treatment of polytraumatized patients crystalloids are preferentially used. To avoid metabolic acidosis, metabolizable anions like lactate or acetate are used to replace chloride in these solutions. We here studied the effects of malated Ringer's in resuscitation of both shock severities in comparison to lactated and acetated Ringer's. Male Wistar rats underwent severe (mean arterial blood pressure (MAP) of 25–30 mmHg) or moderate (MAP 40–45 mmHg) hemorrhagic shock. Adjacent to the shock period animals were resuscitated with acetated (AR), lactated (LR), or malated Ringer's (MR) and observed for 150 min. MR improved survival compared with LR and AR in severe hemorrhagic shock whereas it was equally effective to LR and superior to AR in moderate hemorrhagic shock. In all other parameters tested, MR was also effective similar to the other solutions under these conditions. We conclude that MR is preferable to AR and LR in resuscitation of hemorrhagic shock independent of shock depth. The positive effects of MR may stem from the absence of any adverse impact on energy metabolism under both conditions.
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Eastin TR, Liggin RL, Wilbur LG. Does a Restricted Fluid Resuscitation Strategy Decrease Mortality in Trauma Patients? Ann Emerg Med 2014; 66:49-50. [PMID: 25542815 DOI: 10.1016/j.annemergmed.2014.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Travis R Eastin
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR; Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Rebecca L Liggin
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR; Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Lee G Wilbur
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR; Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
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Bogert JN, Harvin JA, Cotton BA. Damage Control Resuscitation. J Intensive Care Med 2014; 31:177-86. [PMID: 25385695 DOI: 10.1177/0885066614558018] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/09/2014] [Indexed: 01/26/2023]
Abstract
Resuscitation of the hemorrhaging patient has undergone significant changes in the last decade resulting in the concept of damage control resuscitation (DCR). Hemostatic resuscitation aims to address the physiologic derangements found in the hemorrhaging patient, namely coagulopathy, acidosis, and hypothermia. Strategies to achieve this are permissive hypotension, high ratio of plasma and platelet transfusion to packed red blood cell transfusion, and limitation of crystalloid administration. Damage control surgery aims for early hemorrhage control and minimizing operative time by delaying definitive repair until the patient's physiologic status has normalized. Together these strategies constitute DCR and have led to improved outcomes for hemorrhaging patients over the last 2 decades. Recently, DCR has been augmented by both pharmacologic and laboratory adjuncts to improve the care of the hemorrhaging patient. These include thrombelastography as a detailed measure of the clotting cascade, tranexamic acid as an antifibrinolytic, and the procoagulant activated factor VII. In this review, we discuss the strategies that makeup DCR, their adjuncts, and how they fit into the care of the hemorrhaging patient.
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Affiliation(s)
- James N Bogert
- Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA
| | - John A Harvin
- Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA
| | - Bryan A Cotton
- Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA
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12
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Mattox KL. The ebb and flow of fluid (as in resuscitation). Eur J Trauma Emerg Surg 2014; 41:119-27. [PMID: 26038255 DOI: 10.1007/s00068-014-0437-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 07/08/2014] [Indexed: 12/28/2022]
Abstract
Since the early 1960's "resuscitation" following major trauma involved use of replacement crystalloid fluid/estimated blood loss in volumes of 3/1, in the ambulance, emergency room, operating room and surgical intensive care unit. During the past 20 years, MAJOR paradigm shifts have occurred in this concept. As a result hypotensive resuscitation with a view towards restriction of crystalloid, and prevention of complications has occurred. Improved results in both civilian and military environments have been reported. As a result there is new focus on trauma surgical involvement in all aspects of trauma patient management, focus on early aggressive surgical approaches (which may or may not involve an operation), and movement from crystalloid to blood, plasma, and platelet replacement therapy.
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Affiliation(s)
- K L Mattox
- Baylor College of Medicine, Ben Taub General Hospital, One Baylor Plaza, Houston, TX, USA,
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13
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Hammond TN, Holm JL, Sharp CR. A pilot comparison of limited versus large fluid volume resuscitation in canine spontaneous hemoperitoneum. J Am Anim Hosp Assoc 2014; 50:159-66. [PMID: 24659726 DOI: 10.5326/jaaha-ms-6085] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Treatment for hemorrhagic shock secondary to a spontaneous hemoperitoneum includes restoration of IV volume and surgical control of hemorrhage. This study was designed to determine if limited fluid volume resuscitation (LFVR) with hypertonic saline (HS) and hyperoncotic fluids (hydroxyethylstarch [HES]) results in more rapid cardiovascular stabilization in dogs with spontaneous hemoperitoneum versus conventional resuscitation (CR) with large volume resuscitation. Eighteen client-owned dogs presenting in hemorrhagic shock with a spontaneous hemoperitoneum were enrolled. Dogs were randomized to be fluid resuscitated with up to 90 mL/kg of an isotonic crystalloid (CR group) or up to 8 mL/kg of 7.2% Na chloride (i.e., HS) combined with up to 10 mL/kg of 6% HES. Measurements of vital signs, lactate, packed cell volume (PCV), total solids (TS), and blood pressure were made at standard time points. The primary end point was time to stabilization of hemodynamic parameters (measured in min). Dogs in the LFVR group achieved hemodynamic stabilization significantly faster (20 min; range, 10-25 min) than those in the CR group (35 min; range, 15-50 min; P = .027). Future studies are warranted to further investigate potential benefits associated with LFVR in dogs with spontaneous hemoperitoneum.
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Affiliation(s)
- Tara N Hammond
- Department of Emergency/Critical Care, Tufts Veterinary Emergency Treatment & Specialties, Walpole, MA
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14
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Hussmann B, Lendemans S, de Groot H, Rohrig R. Volume replacement with Ringer-lactate is detrimental in severe hemorrhagic shock but protective in moderate hemorrhagic shock: studies in a rat model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R5. [PMID: 24393404 PMCID: PMC4057456 DOI: 10.1186/cc13182] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/30/2013] [Indexed: 11/10/2022]
Abstract
INTRODUCTION To date, there are insufficient data demonstrating the benefits of preclinically administered Ringer-lactate (RL) for the treatment of hemorrhagic shock following trauma. Recent animal experiments have shown that lactate tends to have toxic effects in severe hemorrhagic shock. This study aimed to compare the effects of RL administered in a rat model of severe hemorrhagic shock (mean arterial blood pressure (MAP): 25 to 30 mmHg) and moderate hemorrhagic shock (MAP: 40 to 45 mmHg). METHODS Four experimental groups of eight male Wistar rats each (moderate shock with Ringer-saline (RS), moderate shock with RL, severe shock with RS, severe shock with RL) were established. After achieving the specified depth of shock, animals were maintained under the shock conditions for 60 minutes. Subsequently, reperfusion with RS or RL was performed for 30 minutes, and the animals were observed for an additional 150 minutes. RESULTS All animals with moderate shock that received RL survived the entire study period, while six animals with moderate shock that received RS died before the end of the experiment. Furthermore, animals with moderate shock that received RL exhibited considerable improvements in their acid-base parameters and reduced organ damage. CONCLUSIONS The preclinical use of RL for volume replacement has different effects depending on the severity of hemorrhagic shock. RL exhibits detrimental effects in cases of severe shock, whereas it has pronounced protective effects in cases of moderate shock.
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Rohrig R, Wegewitz C, Lendemans S, Petrat F, de Groot H. Superiority of acetate compared with lactate in a rodent model of severe hemorrhagic shock. J Surg Res 2013; 186:338-45. [PMID: 24124975 DOI: 10.1016/j.jss.2013.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 09/04/2013] [Accepted: 09/05/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recently, we have shown that the use of lactated Ringer's (LR) solution is inferior to pure Ringer's solution (RS) in treatment of severe hemorrhagic shock in rats. The present study was performed to evaluate whether this is a specific effect of lactate or also applies to another metabolizable anion, namely acetate. MATERIAL AND METHODS We subjected male Wistar rats to hemorrhagic shock by dropping the mean arterial blood pressure to 25-30 mm Hg for 60 min, resuscitated with acetated Ringer's (AR) solution, LR solution, RS, or normal saline (NS) within 30 min, and further observed the animals for 180 min. RESULTS Administration of AR solution prolonged median survival to 115 min compared with 50 min for resuscitation with LR solution or 85 and 90 min for NS and RS, respectively. Resuscitation with AR solution and LR solution clearly improved metabolic acidosis compared with NS and RS but tissue injury, indicated by plasma enzyme activities, was most pronounced in the LR solution group, medium in the NS and RS groups, and least in the AR solution group. CONCLUSIONS In severe hemorrhagic shock, resuscitation with both RS and NS is superior to administration of LR solution but initial outcome is even further improved if AR solution is used. Mere amelioration of the acid-base status by AR solution may explain its superior role compared with RS and NS but cannot be responsible for its superiority compared with LR solution. Here, direct injury by lactate has to be discussed.
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Affiliation(s)
- Ricarda Rohrig
- Institut für Physiologische Chemie, Universitätsklinikum Essen, Essen, Germany
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16
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Eardley WGP, Watts SA, Clasper JC. Modelling for conflict: the legacy of ballistic research and current extremity in vivo modelling. J ROY ARMY MED CORPS 2013; 159:73-83. [PMID: 23720587 DOI: 10.1136/jramc-2013-000074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Extremity ballistic injury is unique and the literature intended to guide its management is commonly misinterpreted. In order to care for those injured in conflict and conduct appropriate research, clinicians must be able to identify key in vivo studies, understand their weaknesses and desist the propagation of miscited and misunderstood ballistic dogma. This review provides the only inclusive critical overview of key studies of relevance to military extremity injury. In addition, the non-ballistic studies of limb injury, stabilisation and contamination that will form the basis from which future small animal extremity studies are constructed are presented. With an awareness of the legacy of military wound models and an insight into available generic models of extremity injury and contamination, research teams are well placed to optimise future military extremity injury management.
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Affiliation(s)
- William G P Eardley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Institute of Research and Development, Birmingham, UK.
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17
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Schmidt BM, Rezende-Neto JB, Andrade MV, Winter PC, Carvalho MG, Lisboa TA, Rizoli SB, Cunha-Melo JR. Permissive hypotension does not reduce regional organ perfusion compared to normotensive resuscitation: animal study with fluorescent microspheres. World J Emerg Surg 2012; 7 Suppl 1:S9. [PMID: 23531188 PMCID: PMC3424975 DOI: 10.1186/1749-7922-7-s1-s9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction The objective of this study was to investigate regional organ perfusion acutely following uncontrolled hemorrhage in an animal model that simulates a penetrating vascular injury and accounts for prehospital times in urban trauma. We set forth to determine if hypotensive resuscitation (permissive hypotension) would result in equivalent organ perfusion compared to normotensive resuscitation. Methods Twenty four (n=24) male rats randomized to 4 groups: Sham, No Fluid (NF), Permissive Hypotension (PH) (60% of baseline mean arterial pressure - MAP), Normotensive Resuscitation (NBP). Uncontrolled hemorrhage caused by a standardised injury to the abdominal aorta; MAP was monitored continuously and lactated Ringer’s was infused. Fluorimeter readings of regional blood flow of the brain, heart, lung, kidney, liver, and bowel were obtained at baseline and 85 minutes after hemorrhage, as well as, cardiac output, lactic acid, and laboratory tests; intra-abdominal blood loss was assessed. Analysis of variance was used for comparison. Results Intra-abdominal blood loss was higher in NBP group, as well as, lower hematocrit and hemoglobin levels. No statistical differences in perfusion of any organ between PH and NBP groups. No statistical difference in cardiac output between PH and NBP groups, as well as, in lactic acid levels between PH and NBP. NF group had significantly higher lactic acidosis and had significantly lower organ perfusion. Conclusions Hypotensive resuscitation causes less intra-abdominal bleeding than normotensive resuscitation and concurrently maintains equivalent organ perfusion. No fluid resuscitation reduces intra-abdominal bleeding but also significantly reduces organ perfusion.
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Affiliation(s)
- Bruno M Schmidt
- Federal University of Minas Gerais, Av, Prof, Alfredo Balena 190, Belo Horizonte, MG, 30130-100, Brazil.
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18
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Alsawadi A. The clinical effectiveness of permissive hypotension in blunt abdominal trauma with hemorrhagic shock but without head or spine injuries or burns: a systematic review. Open Access Emerg Med 2012; 4:21-9. [PMID: 27147860 PMCID: PMC4753977 DOI: 10.2147/oaem.s30666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Trauma is a major cause of death and disability. The current trend in trauma management is the rapid administration of fluid as per the Advanced Trauma Life Support guidelines, although there is no evidence to support this and even some to suggest it might be harmful. Some guidelines, protocols, and recommendations have been established for the use of permissive hypotension although there is reluctance concerning its application in blunt injuries. Objectives The aim of this review is to determine whether there is evidence of the use of permissive hypotension in the management of hemorrhagic shock in blunt trauma patients. This review also aims to search for any reason for the reluctance to apply permissive hypotension in blunt injuries. Methods This systematic review has followed the steps recommended in the Cochrane Handbook for Systematic Reviews of Interventions. It is also being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement and checklist. Database searches of MEDLINE, EMBASE, the Centre for Reviews and Dissemination databases and the Cochrane Library were made for eligible studies as well as journal searches. Inclusion criteria included systematic reviews that have similar primary questions to this review and randomized controlled trials where patients with blunt torso injuries and hemorrhagic shock were not excluded. Rapid or early fluid administration was compared with controlled or delayed fluid resuscitation and a significant outcome was obtained. Results No systematic reviews attempting to answer similar questions were found. Two randomized controlled trials with mixed types of injuries in the included patients found no significant difference between the groups used in each study. Data concerning the question of this review was sought after these papers were appraised. Conclusion The limited available data are not conclusive. However, the supportive theoretical concept and laboratory evidence do not show any reason for treating blunt injuries differently from other traumatic injuries. Moreover, permissive hypotension is being used for some nontraumatic causes of hemorrhagic shock and in theater. Therefore, this should encourage interested researchers to continue clinical work in this important field.
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Affiliation(s)
- Abdulrahman Alsawadi
- Colchester Hospital University NHS Foundation Trust, Colchester, Essex, United Kingdom
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19
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Almac E, Aksu U, Bezemer R, Jong W, Kandil A, Yuruk K, Demirci-Tansel C, Ince C. The acute effects of acetate-balanced colloid and crystalloid resuscitation on renal oxygenation in a rat model of hemorrhagic shock. Resuscitation 2012; 83:1166-72. [PMID: 22353638 DOI: 10.1016/j.resuscitation.2012.02.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/22/2011] [Accepted: 02/07/2012] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Fluid resuscitation therapy is the initial step of treatment for hemorrhagic shock. In the present study we aimed to investigate the acute effects of acetate-balanced colloid and crystalloid resuscitation on renal oxygenation in a rat model of hemorrhagic shock. We hypothesized that acetate-balanced solutions would be superior in correcting impaired renal perfusion and oxygenation after severe hemorrhage compared to unbalanced solutions. METHODS In anesthetized, mechanically ventilated rats, hemorrhagic shock was induced by withdrawing blood from the femoral artery until mean arterial pressure (MAP) was reduced to 30 mmHg. One hour later, animals were resuscitated with either hydroxyethyl starch (HES, 130/0.42 kDa) dissolved in saline (HES-NaCl; n=6) or a acetate-balanced Ringer's solution (HES-RA; n=6), as well as with acetated Ringer's solution (RA; n=6) or 0.9% NaCl alone (NaCl; n=6) until a target MAP of 80 mmHg was reached. Oxygen tension in the renal cortex (CμPO2), outer medulla (MμPO2), and renal vein were measured using phosphorimetry. RESULTS Hemorrhagic shock (MAP=30 mmHg) significantly decreased renal oxygenation and oxygen consumption. Restoring the MAP to 80 mmHg required 24.8±1.7 ml of NaCl, 21.7±1.4 ml of RA, 5.9±0.5 ml of HES-NaCl (p<0.05 vs. NaCl and RA), and 6.0±0.4 ml of HES-RA (p<0.05 vs. NaCl and RA). NaCl, RA, and HES-NaCl resuscitation led to hyperchloremic acidosis, while HES-RA resuscitation did not. Only HES-RA resuscitation could restore renal blood flow back to ∼85% of baseline level (from 1.9±0.1 ml/min during shock to 5.1 ml±0.2 ml/min 60 min after HES-RA resuscitation) which was associated with an improved renal oxygenation (CμPO2 increased from 24±2 mmHg during shock to 50±2 mmHg 60 min after HES-RA resuscitation) albeit not to baseline level. At the end of the protocol, creatinine clearance was decreased in all groups with no differences between the different resuscitation groups. CONCLUSION While resuscitation with the NaCl and RA (crystalloid solutions) and the HES-NaCl (unbalanced colloid solution) led to hyperchloremic acidosis, resuscitation with the HES-RA (acetate-balanced colloid solution) did not. The HES-RA was furthermore the only fluid restoring renal blood flow back to ∼85% of baseline level and most prominently improved renal microvascular oxygenation.
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Affiliation(s)
- Emre Almac
- Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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20
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Hextend and 7.5% hypertonic saline with Dextran are equivalent to Lactated Ringer's in a swine model of initial resuscitation of uncontrolled hemorrhagic shock. ACTA ACUST UNITED AC 2012; 71:1755-60. [PMID: 22182885 DOI: 10.1097/ta.0b013e3182367b1c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal fluid strategy for the early treatment of trauma patients remains highly debated. Our objective was to determine the efficacy of an initial bolus of resuscitative fluids used in military and civilian settings on the physiologic response to uncontrolled hemorrhagic shock in a prospective, randomized, blinded animal study. METHODS Fifty anesthetized swine underwent central venous and arterial catheterization followed by celiotomy. Grade V liver injury was performed, followed by 30 minutes of uncontrolled hemorrhage. Then, liver packing was completed, and fluid resuscitation was initiated over 12 minutes with 2 L normal saline (NS), 2 L Lactated Ringer's (LR), 250 mL 7.5% hypertonic saline with 3% Dextran (HTS), 500 mL Hextend (HEX), or no fluid (NF). Animals were monitored for 2 hours postinjury. Blood loss after initial hemorrhage, mean arterial pressure (MAP), tissue oxygen saturation (StO2), hematocrit, pH, base excess, and lactate were measured at baseline, 1 hour, and 2 hours. RESULTS NF group had less post-treatment blood loss compared with other groups. MAP and StO2 for HEX, HTS, and LR at 1 hour and 2 hours were similar and higher than NF. MAP and StO2 did not differ between NS and NF, but NS resulted in decreased pH and base excess. CONCLUSIONS Withholding resuscitative fluid results in the least amount of posttreatment blood loss. In clinically used volumes, HEX and HTS are equivalent to LR with regard to physiologic outcomes and superior to NF. NS did not provide a measurable improvement in outcome compared with NF and resulted in increased acidosis.
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21
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Fernández-Hinojosa E, Murillo-Cabezas F, Puppo-Moreno A, Leal-Noval SR. [Treatment alternatives in massive hemorrhage]. Med Intensiva 2012; 36:496-503. [PMID: 22321860 DOI: 10.1016/j.medin.2011.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 11/07/2011] [Accepted: 11/14/2011] [Indexed: 10/14/2022]
Abstract
Massive hemorrhage is the main cause of mortality and morbidity in trauma patients, and is one of the most important causes in any patient following major surgery. Conventional treatment consists of volume replacement, including the transfusion of blood products, so that tissue perfusion and oxygenation may be maintained. Associated hypothermia, acidosis and coagulopathy is a lethal triad. This review focuses on the latest therapeutic management of massive hemorrhage. The authors advocate the use of crystalloids as per protocol (controlled volumes) in order to achieve a systolic blood pressure of 85mmHg. The administration of the three blood products (red cells, plasma, and platelets) should be on a 1:1:1 basis. Where possible, this in turn should be guided by thromboelastography performed at point of care near the patient. Coagulopathy can occur early and late. With the exception of tranexamic acid, the cost-benefit relationships of the hemostatic agents, such as fibrinogen, prothrombin complex, and recombinant F VII, are subject to discussion.
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Affiliation(s)
- E Fernández-Hinojosa
- Servicio de Cuidados Críticos, Hospital Universitario Virgen del Rocío, Sevilla, España
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22
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Small volume 7.5% NaCl with 6% Dextran-70 or 6% and 10% hetastarch are associated with arrhythmias and death after 60 minutes of severe hemorrhagic shock in the rat in vivo. ACTA ACUST UNITED AC 2011; 70:1444-52. [PMID: 20805759 DOI: 10.1097/ta.0b013e3181e99c63] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hypertonic saline solutions in combination with colloids may have some applications in critically ill patients. Our aim was to examine the effects of small volumes (0.7-1 mL/kg intravenous) of 7.5% NaCl with different colloids on cardiac stability, hemodynamics, and mortality after severe hemorrhagic shock. METHODS Male fed Sprague-Dawley rats (300-450 g, n = 48) were anesthetized and randomly assigned to one of six groups: (1) untreated (bleed only), (2) 7.5% NaCl, (3) 7.5% NaCl/6% dextran-70, (4) 7.5% NaCl/6% hetastarch (HES), (5) 6% HES alone, and (6) 7.5% NaCl/10% HES. Hemorrhagic shock was induced by phlebotomy until the mean arterial pressure (MAP) was 35 mm Hg to 40 mm Hg and continued for 20 minutes until ∼40% blood loss. Animals were left in shock for 60 minutes at 34°C. 0.3 mL (<4% of shed blood) was injected as a 10 seconds bolus into the femoral vein. Lead II electrocardiogram, blood pressures, MAP, and heart rate were monitored. RESULTS Untreated rats were highly arrhythmogenic with 38% mortality. 7.5% NaCl increased MAP from 39 mm Hg to 44 mm Hg with no severe arrhythmias or mortality. Dextran-70 increased MAP from 38 mm Hg to 49 mm Hg, transiently increased QRS amplitude (1.5 times) and was arrhythmogenic affecting 50% of animals with no deaths. Addition of 6% HES to hypertonic saline resulted in aberrant arrhythmias and 38% mortality. Six percent HES alone was proarrhythmic and led to 38% mortality. 7.5% NaCl with 10% HES resulted in 100% mortality (p < 0.05) from arrhythmias within 5 minutes of resuscitation. CONCLUSIONS Small volumes of 7.5% NaCl led to fewer arrhythmias and a 2.6 times survival benefit over untreated rats, and a partial resuscitation of MAP into the "permissive range." Dextran-70 or HES in 7.5% NaCl were proarrhythmic and HES led to increased mortality (p < 0.05). Because optimal heart function is critical for successful resuscitation, care should be exercised when using dextran-70 or 6 and 10% HES in small volume hypertonic saline solutions for early hypotensive resuscitation.
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23
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Riha GM, Schreiber MA. Update and new developments in the management of the exsanguinating patient. J Intensive Care Med 2011; 28:46-57. [PMID: 21747123 DOI: 10.1177/0885066611403273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Definitive management of the exsanguinating patient continues to challenge providers in multiple specialties. Significant hemorrhage may be encountered in a variety of patient care circumstances. Over the past two decades, the vast majority of data and evidence regarding transfusion in the exsanguinating patient has been based upon the trauma literature, and a large amount of recent research has investigated this subject area. In addition to the care of trauma patients, the data which have emerged can also be extrapolated to the treatment of nontrauma patients undergoing transfusion for major hemorrhage. The concept of massive transfusion is an evolving paradigm, and numerous investigations have challenged old principles while creating new controversies. The current review will examine the latest developments in the management of patients with profound hemorrhage. The challenges of dealing with the "lethal triad" will be discussed, as will the various aspects of damage control and hemostatic resuscitation. The latest literature and controversy regarding massive transfusions and massive transfusion protocols will be elucidated with inclusion of data from recent military experiences. Finally, adjuncts including the most recent advances in hemorrhage control, identification of early predictors for massive transfusion, and utilization of pharmacologic and complementary factor agent therapy will be discussed.
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Affiliation(s)
- Gordon M Riha
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Science University, Portland, OR 97239, USA
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24
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Sánchez Pérez E, Garutti Martínez I. [Hypotensive resuscitation of the polytrauma patient with hemorrhagic shock]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:648-655. [PMID: 22283017 DOI: 10.1016/s0034-9356(10)70301-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Hemorrhagic shock is a significant cause of death in hospital practice, yet the management of this event in the period prior to definitive surgical hemostasis has changed little in 40 years. Currently, the standard treatment of resuscitation by means of fluid therapy to re-establish normal pressure and volume is based on animal models from the 1950s and 1960s; these studies will be reviewed in this article. However, new experimental models of hemorrhagic shock that have emerged in the last 3 decades are based on uncontrolled bleeding and are more similar to real-life situations. Recent studies using these models have demonstrated increased survival when polytrauma patients with hemorrhagic shock are deliberately allowed to remain in a moderate level of hypotension, a strategy referred to as hypotensive resuscitation. Finally, we review clinical trials of hypotensive resuscitation in hemorrhagic shock as well as studies indirectly related to this management approach. We conclude that hypotensive resuscitation is a promising treatment for use in cases of hemorrhagic shock that occur either in or out of hospital; however, we believe that more trials should be done before it can be considered a standard treatment.
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Affiliation(s)
- E Sánchez Pérez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario Gregorio Marañón, Madrid.
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25
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McCunn M, Gordon EKB, Scott TH. Anesthetic concerns in trauma victims requiring operative intervention: the patient too sick to anesthetize. Anesthesiol Clin 2010; 28:97-116. [PMID: 20400043 DOI: 10.1016/j.anclin.2010.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Trauma is the third leading cause of death in the U.S. Timely acute care anesthetic management of patients following traumatic injury may improve outcome. Recognition of highly-mortal injuries to the brain, heart, lungs, liver, and pelvis should guide trauma-specific management strategies. Rapid intraoperative treatment of life-threatening conditions following injury includes the use of 'controlled-under resuscitation' of fluid administration until surgical hemorrhage control, early factor replacement in addition to transfusion of packed red blood cells, and use of adjuvant therapies such as recombinant factor VIIa. These treatment strategies, other recent developments in acute trauma resuscitation, and a review of associated co-existing medical conditions that may impact mortality, are presented.
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Affiliation(s)
- Maureen McCunn
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Dulles 6, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Abstract
Identification of occult shock is a major clinical problem compounded by inadequate criteria for assessing the efficacy of fluid resuscitation. We suggest that these problems may be resolved in part by understanding both the physiological mechanisms underlying oxygen debt accumulation and, more importantly, the debt repayment schedule during resuscitation. We present a simplified tutorial that incorporates the concept of the oxygen supply-delivery relationship with that of oxygen debt and show how this is relevant to the understanding of shock and resuscitation. Use of oxygen debt metrics as end points for shock have been controversial; however, much of the controversy may have been due to incomplete understanding of basic physiology of shock and semantic confusion between the various metrics proposed as end points. Here, we provide working definitions for the frequently misunderstood concepts of oxygen deficit and oxygen debt and discuss the relatively novel concept of oxygen debt repayment schedule. We introduce predictions made on the basis of data derived from animal models of hemorrhagic shock. Our calculations suggest that the amount of debt repaid in the first 2 h of resuscitation, rather than the restoration of volume per se, influences the likelihood of organ damage. Because of difficulties inherent in measuring oxygen debt in the prehospital and emergency settings, various metabolic end points such as lactate and base deficit have been proposed as surrogates. We demonstrate the heuristic value of this model in providing a predictive framework for both the optimum therapeutic time window and optimum fluid loadings before critical transitions to an irreversible shock state can occur. The model also provides an unambiguous and objective standard for quantifying the behavior of various postulated shock "markers".
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Improved survival time with combined early blood transfusion and fluid administration in uncontrolled hemorrhagic shock in rats. ACTA ACUST UNITED AC 2010; 68:312-6. [PMID: 20154543 DOI: 10.1097/ta.0b013e3181c48970] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test whether early blood administration combined with crystalloid solution infusion may prolong survival in a clinically relevant model of ongoing uncontrolled life-threatening hemorrhage. METHODS Light anesthesia was induced with halothane in 24 rats, and spontaneous breathing was maintained. Uncontrolled hemorrhagic shock was induced by withdrawal of blood at 2.5 mL/100 g over a 15-minute period, followed by 75% tail amputation. At 10 minutes after tail cutting, rats were randomized into four groups (n = 6 each): group 1, receiving 3 mL of shed blood for 5 minutes followed by 9 mL of lactated Ringer's (LR) solution for 15 minutes; group 2, receiving 9 mL of LR solution for 15 minutes followed by 3 mL of shed blood for 5 minutes; group 3, receiving 9 mL of LR solution only for 15 minutes; group 4, receiving neither of shed blood nor LR solution. Rats were then observed until death or a maximum of 180 minutes. RESULT Mean survival time was 138 +/- 30 minutes, 108 +/- 22 minutes, 79 +/- 13 minutes, and 55 +/- 18 minutes for groups 1, 2, 3, and 4, respectively (p < 0.05 among the four groups). Additional blood loss from the tail stump did not differ significantly between the three treatment groups. CONCLUSIONS In a model of uncontrolled hemorrhagic shock in rats, a resuscitation regimen using crystalloids agent alone is not ideal, and even a brief delay in blood administration worsens survival. Early blood administration combined with crystalloid solution infusion seems ideal.
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Abreu GFSD, Coelho ARB, Aguiar JLDA, Moura Filho SA. Cardiocirculatory changes in hemorrhagic shock induced in pigs submitted to three distinct therapeutic methods. Acta Cir Bras 2010; 25:126-30. [DOI: 10.1590/s0102-86502010000100025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 11/17/2009] [Indexed: 11/22/2022] Open
Abstract
PURPOSE: To evaluate and compare the response of pigs submitted to hemorrhagic shock and treated using three different strategies. METHODS: Thirty-five Dalland pigs were divided into four groups: Control; Bleeding; Saline and Saline + Red Cell Concentrate. Parameters evaluated: heart rate (HR), mean arterial blood pressure (MAP) and central vein pressure (CVP).Hemorrhagic shock was induced by removing (624.25±64.55), (619.30±44.94) and (664.23±39.96) ml of blood respectively, with the following treatment: Bleeding Group - zero volume replacement; Saline Group - replacement with 676 ml of 0.9% saline solution; Saline + Red Cell Concentrate Group - replacement with 440 ml of 0.9% saline solution + 291 ml of red cell concentrate. The treatment was evaluated after 10 (T3), 30 (T4), 45 (T5) and 60 (T6) minutes. RESULTS: HR: No statistically significant difference was found between the Bleeding and Saline [p=1.000], Bleeding and Saline + Red Cell Concentrate [p=1.000], and Saline and Saline + Red Cell Concentrate [p=0.721] groups. MAP; Significant differences were found between all the groups studied. CVP: No significant difference was found between the groups. CONCLUSION: Non-replacement and euvolemic resuscitation maintained a satisfactory hemodynamic pattern in controlled severe hemorrhagic shock in swine. The euvolemic replacement strategies exceeded the limit values of MAP for rebleeding.
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Abstract
Sepsis is a major cause of mortality and morbidity in the trauma patient. Sepsis following traumatic injury is related to the type of injury, together with the extent of injury and the anatomical location. Burn injuries are associated with the highest risk of sepsis. The diagnosis of sepsis in the trauma patient remains difficult. Interpretation of abnormal results is key to successful diagnosis, particularly in conjunction with clinical findings. This review will consider the specific features of sepsis in the context of trauma relating to epidemiology, risk factors, diagnosis and management.
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Affiliation(s)
- Robert Thornhill
- Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Raddlebarn Road, Selly Oak, Birmingham, B29 6JD, UK, , Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
| | - Dan Strong
- Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
| | - Suresh Vasanth
- Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
| | - Iain Mackenzie
- Department of Critical Care Medicine, Queen Elizabeth Medical Centre, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK, School of Clinical and Experimental Medicine, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Abstract
Massive transfusion (MT) is used for the treatment of uncontrolled hemorrhage. Earlier definitive control of life-threatening hemorrhage has significantly improved patient outcomes, but MT is still required. A number of recent advances in the area of MT have emerged, including the use of "hypotensive" or "delayed" resuscitation for victims of penetrating trauma before hemorrhage is controlled and "hemostatic resuscitation" with increased use of plasma and platelet transfusions in an attempt to maintain coagulation. These advances include the earlier use of hemostatic blood products (plasma, platelets, and cryoprecipitate), recombinant factor VIIa as an adjunct to the treatment of dilutional and consumptive coagulopathy, and a reduction in the use of isotonic crystalloid resuscitation. MT protocols have been developed to simplify and standardize transfusion practices. The authors of recent studies have advocated a 1:1:1 ratio of packed RBCs to fresh frozen plasma to platelet transfusions in patients requiring MT to avoid dilutional and consumptive coagulopathy and thrombocytopenia, and this has been associated with decreased mortality in recent reports from combat and civilian trauma. Earlier assessment of the exact nature of abnormalities in hemostasis has also been advocated to direct specific component and pharmacologic therapy to restore hemostasis, particularly in the determination of ongoing fibrinolysis.
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Abstract
PURPOSE OF REVIEW To bring together in one review article, the most current and relevant evidence relating to military trauma resuscitation. RECENT FINDINGS The main themes highlighted by this review are coagulopathy of trauma shock (CoTS), damage control resuscitation, haemostatic resuscitation, the management of massive transfusion, use of adjuvant drugs for haemostasis and use of an empiric massive transfusion protocol. SUMMARY The review aims to educate the readership in recent advances in trauma practice, culminating in a novel empiric massive transfusion algorithm seamlessly guiding the clinician through the initial resuscitation stage resulting in reduced mortality, morbidity, coagulopathy and decreased overall blood product usage.
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Affiliation(s)
- Rob Dawes
- 16 Air Assault Medical Regiment, Royal Army Medical Corps, UK
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Abstract
PURPOSE OF REVIEW Major trauma is often associated with hemorrhage and transfusion of blood and blood products, which are all associated with adverse clinical outcome. The aim of this review is to emphasize why bleeding and coagulation has to be monitored closely in trauma patients and to discuss the rationale behind modern and future transfusion strategies. RECENT FINDINGS Hemorrhage is a major cause of early death after trauma. Apart from the initial injuries, hemorrhage is significantly promoted by coagulopathy. Early identification of the underlying cause of hemorrhage with coagulation tests (routine and bedside) in conjunction with blood gas analysis allow early goal-directed treatment of coagulation disorders and anemia, thereby stopping bleeding and reducing transfusion requirements. These treatment options have to be adapted to the civilian and noncivilian sector. Transfusion of blood and its components is critical in the management of trauma hemorrhage, but is per se associated with adverse outcome. Decisions must weigh the potential benefits and harms. SUMMARY Future transfusion strategies are based on early and continuous assessment of the bleeding and coagulation status of trauma patients. This allows specific and goal-directed treatment, thereby optimizing the patient's coagulation status early, minimizing the patient's exposure to blood products, reducing costs and improving the patient's outcome.
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Early Norepinephrine Infusion Delays Cardiac Arrest After Hemorrhagic Shock in Rats. J Emerg Med 2009; 37:376-82. [DOI: 10.1016/j.jemermed.2008.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2008] [Revised: 05/16/2008] [Accepted: 07/09/2008] [Indexed: 11/24/2022]
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Vascular injuries after blunt chest trauma: diagnosis and management. Scand J Trauma Resusc Emerg Med 2009; 17:42. [PMID: 19751511 PMCID: PMC2749011 DOI: 10.1186/1757-7241-17-42] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 09/14/2009] [Indexed: 01/12/2023] Open
Abstract
Background Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma. Methods A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise. Discussion Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.
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Polymerized bovine hemoglobin can improve small-volume resuscitation from hemorrhagic shock in hamsters. Shock 2009; 31:300-7. [PMID: 18636045 DOI: 10.1097/shk.0b013e318180ff63] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Systemic and microvascular hemodynamic responses to hemorrhagic shock volume resuscitation with hypertonic saline followed by infusion of polymerized bovine hemoglobin (PBH) at different concentrations were studied in the hamster window chamber model to determine the role of plasma oxygen-carrying capacity and vasoactivity during resuscitation. Moderate hemorrhagic shock was induced by arterial controlled bleeding of 50% of blood volume (BV), and a hypovolemic state was maintained for 1 h. Volume was restituted by infusion of hypertonic saline (7.5% NaCl), 3.5% of BV, followed by 10% of BV of PBH at 2 different concentrations. Resuscitation was followed for 90 min and was carried out using 13 gPBH/dL (PBH13), PBH diluted to 4 gPBH/dL in albumin solution at matching colloidal osmotic pressure (PBH4), and an albumin-only solution at matching colloidal osmotic pressure (PBH0). Systemic parameters, microvascular hemodynamics, and functional capillary density were determined during hemorrhage, hypovolemic shock, and resuscitation. The PBH13 caused higher arterial pressure without reverting vasoconstriction and hypoperfusion. The PBH4 and PBH0 had lower MAP and partially reverted vasoconstriction. Only treatment with PBH4 restored perfusion and functional capillary density when compared with PBH13 and PBH0. Blood gas parameters and acid-base balance recovered proportionally to microvascular perfusion. Tissue PO2 was significantly improved in the PBH4 group, showing that limited restoration of oxygen-carrying capacity is beneficial and compensates for the effects of vasoactivity, a characteristic of molecular hemoglobin solutions proposed as blood substitutes.
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Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. ACTA ACUST UNITED AC 2008; 65:951-60. [PMID: 18849817 DOI: 10.1097/ta.0b013e318187e15b] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Beside the often discussed topics of consumption and dilution coagulopathy, additional perioperative impairments of coagulation are caused by acidosis, hypocalcemia, anemia, hypothermia, and combinations. METHODS Reviewing current literature, cutoff values of these parameters become obvious at which therapy should commence. RESULTS A notable impairment of hemostasis arises at a pH < or = 7.1. Similar effects are caused by a BE of -12.5 or less. Thus, in case of severe bleeding, buffering toward physiologic pH values is recommended, especially with massive transfusions of older RBCCs displaying exhausted red blood cell buffer systems. It completes the optimization of the volume homeostasis to ensure an adequate tissue perfusion. Combining beneficial cardiovascular and coagulation effects, the level for ionized calcium concentration should be held > or = 0.9 mmol/L. From the hemostatic point of view, the optimal Hct is higher than the one required for oxygenation. Even without a "classical" transfusion trigger, the therapy of acute, persistent bleeding should aim at reaching an Hct > or = 30%. A core temperature of < or = 34 degrees C causes a decisive impairment of hemostasis. A controlled hypotensive fluid resuscitation should aim at reaching a mean arterial pressure of > or = 65 mm Hg (possibly higher for cerebral trauma). Prevention and later aggressive therapy of hypothermia by exclusive infusion of warmed fluids and the use of warming devices are prerequisites for the cure of traumatic coagulopathy. Combined appearance of single preconditions cause additive impairments of the coagulation system. CONCLUSIONS The prevention and timely correction, especially of the combination acidosis plus hypothermia, is crucial for the treatment of hemorrhagic coagulopathy.
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LACTATE PROFILES AS A RESUSCITATION ASSESSMENT TOOL IN A RAT MODEL OF BATTLEFIELD HEMORRHAGE RESUSCITATION. Shock 2008; 30:48-54. [DOI: 10.1097/shk.0b013e31815d1a3d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cabrales P, Tsai AG, Intaglietta M. Increased plasma viscosity prolongs microhemodynamic conditions during small volume resuscitation from hemorrhagic shock. Resuscitation 2008; 77:379-86. [PMID: 18308459 DOI: 10.1016/j.resuscitation.2008.01.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 01/02/2008] [Indexed: 11/29/2022]
Abstract
Systemic and microvascular hemodynamic responses to hemorrhagic shock resuscitation with hypertonic saline (HTS, 7.5% NaCl) followed with a small volume of plasma expander were studied in the hamster window chamber model to determine the role of plasma expander viscosity in the acute resuscitation outcome. Moderate hemorrhagic shock was induced by arterial controlled bleeding of 50% of blood volume (BV) and the hypovolemic state was maintained for 1 h. Volume restitution was performed by infusion of HTS, 3.5% of BV followed by 10% of BV plasma expanders. Resuscitation was followed for 90 min. The experimental groups were named based on the plasma expanders infused after the HTS, namely: [Hextend], Hextend (6% Hetastarch 670 kDa in lactated electrolyte solution, 4 cp), [Hextend+V], Hextend with viscosity enhanced by the addition of 0.4% alginate, 8 cp, and [NVR] no volume resuscitation as control group. Measurement of systemic parameters, microvascular hemodynamics and capillary perfusion were performed during hemorrhage, shock and resuscitation. Restitution with Hextend yielded the higher mean arterial pressure (MAP), followed by Hextend+V and NVR. Increasing plasma viscosity did not increase peripheral vascular resistance. Functional capillary density (FCD) was higher for Hextend+V than Hextend and NVR. The level of restoration of acid-base balance correlated with microvascular perfusion and was significantly improved with Hextend+V when compared to Hextend and NVR. These results suggest the importance of restoration of blood rheological properties through enhancing plasma viscosity, influencing the re-establishment of microvascular perfusion during small volume resuscitation from hemorrhagic shock.
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Affiliation(s)
- Pedro Cabrales
- La Jolla Bioengineering Institute, La Jolla, CA 92037, USA.
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The effect of hypoxemic resuscitationfrom hemorrhagic shock on blood pressure restoration and on oxidative and inflammatory responses. Intensive Care Med 2007; 34:1133-41. [DOI: 10.1007/s00134-007-0940-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 11/06/2007] [Indexed: 11/26/2022]
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Stahel PF, Smith WR, Moore EE. Hypoxia and hypotension, the "lethal duo" in traumatic brain injury: implications for prehospital care. Intensive Care Med 2007; 34:402-4. [PMID: 17938886 DOI: 10.1007/s00134-007-0889-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Accepted: 09/14/2007] [Indexed: 10/22/2022]
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Abstract
Capnometry is a non-invasive monitoring technique which allows fast and reliable insight into ventilation, circulation, and metabolism. In the prehospital setting it is mainly used to confirm correct tracheal tube placement. In addition it is a useful indicator of efficient ongoing cardiopulmonary resuscitation due to its correlation with cardiac output, and successful resuscitation. It helps to confirm the diagnosis of pulmonary thromboembolism and to sustain adequate ventilation in mechanically ventilated patients. In patients with haemorrhage, capnometry provides improved continuous haemodynamic monitoring, insight into adequacy of tissue perfusion, optimisation within current hypotensive fluid resuscitation strategy, and prevention of shock progression through controlled fluid administration.
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Affiliation(s)
- Dejan Kupnik
- Center for Emergency Medicine, Prehospital Unit, Ulica talcev 9, Maribor, Slovenia.
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Driessen B, Zarucco L, Gunther RA, Burns PM, Lamb SV, Vincent SE, Boston RA, Jahr JS, Cheung ATW. Effects of low-volume hemoglobin glutamer-200 versus normal saline and arginine vasopressin resuscitation on systemic and skeletal muscle blood flow and oxygenation in a canine hemorrhagic shock model. Crit Care Med 2007; 35:2101-9. [PMID: 17581486 DOI: 10.1097/01.ccm.0000277040.31978.3d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that low-volume resuscitation with hemoglobin glutamer-200 improves hemodynamic function and tissue oxygenation, whereas arginine vasopressin resuscitation improves blood pressures more than low-volume saline or hemoglobin glutamer infusion but compromises systemic and muscle blood flow and oxygenation. DESIGN Randomized laboratory investigation. SETTING University research facility. SUBJECTS Nineteen dogs. INTERVENTIONS Dogs were instrumented to determine heart rate; arterial, central venous, pulmonary arterial, and pulmonary arterial occlusion pressures; cardiac output; and quadriceps muscle blood flow and oxygen tension (PMo2). Total and plasma hemoglobin, oxygen content, lactate, pH, standard base excess, and arginine vasopressin levels were determined, and systemic oxygen delivery (Do2I) and extraction ratio were calculated. Measurements were made before and 30 mins following hemorrhage. Dogs were resuscitated over 60 mins with saline (8.5 mL/kg), arginine vasopressin (0.4 IU/kg bolus plus 0.08 IU x kg x min), or 1:1 diluted hemoglobin glutamer-200. Recordings were then repeated. Subsequently, animals received 30 mL/kg shed blood (60 mL x kg x hr), and recordings were repeated immediately and 1 hr later. MEASUREMENTS AND MAIN RESULTS Hemorrhage ( approximately 52 mL/kg) caused characteristic changes in hemodynamic, hematologic, systemic PMo2, and acid-base variables. Saline resuscitation increased both Do2I and muscle perfusion by 42% and 51%, while arginine vasopressin treatment reduced heart rate by 31% and increased mean arterial pressure by 22% but not cardiac output, Do2I, or muscle blood flow, resulting in a further decrease of PMo2 by 68% and worse metabolic acidosis. Hemoglobin glutamer-200 infusion caused systemic and pulmonary vasoconstriction, however, without deterioration of cardiac output, Do2I, muscle blood flow, or PMo2 despite lack of oxygen content increase. Blood transfusion restored most variables. CONCLUSIONS Low-volume crystalloid or hemoglobin glutamer-200 resuscitation posthemorrhage may improve (but not restore) macro- and microvascular functions and tissue oxygenation, while arginine vasopressin infusion may only improve blood pressures and result in lower overall systemic perfusion compared with low-volume saline or hemoglobin glutamer-200 treatment and worsening of anaerobic conditions in skeletal muscle.
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Affiliation(s)
- Bernd Driessen
- University of Pennsylvania, School of Veterinary Medicine, Department of Clinical Studies, Section of Critical Care, New Bolton Center, Kennett Square, PA, USA.
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Reynolds PS, Barbee RW, Skaflen MD, Ward KR. LOW-VOLUME RESUSCITATION COCKTAIL EXTENDS SURVIVAL AFTER SEVERE HEMORRHAGIC SHOCK. Shock 2007; 28:45-52. [PMID: 17483745 DOI: 10.1097/shk.0b013e31802eb779] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After severe hemorrhage, low-volume resuscitation with hypertonic fluids is increasingly preferred to more aggressive resuscitation strategies. Oxygen delivery to the tissues may be improved by augmentation with hemoglobin [Hb]-based oxygen-carrying compounds (HBOCs); however, previous studies have reported negative outcomes presumably related to extravasation of tetrameric Hb. The purpose of this study was to evaluate a novel large molecular weight polymer of cross-linked bovine Hb (OxyVita; OXYVITA Inc, New Windsor, NY) in a cocktail of hypertonic saline and Hextend (HX; HBOC-C) as an alternative to standard small-volume resuscitation using Hextend (HX) only. Outcomes were survival to 3 h and duration of MAP support more than 60 mmHg without additional fluid support. Conscious male Long-Evans rats were hemorrhaged to 60% total blood volume over 40 min. There were 4 groups: HBOC-C administered in a pressure-titrated infusion, HX titration, HBOC-C administered as a bolus, and HX bolus. Cardiovascular parameters, arterial gases, acid-base status, metabolites, electrolytes, Hb level, and oxygen saturation were measured at baseline, during each 20% hemorrhage increment, and 1, 2, and 3 h after the initiation of hemorrhage. Small-volume resuscitation with HBOC-C significantly improved survival to 3 h and improved MAP support times regardless of method of administration. However, physiological status at the end of hemorrhage significantly influenced survival regardless of resuscitation treatment. These results suggest that HBOC-augmented hypertonic cocktails are of promise in improving survival and providing target MAP support during small-volume resuscitation. Experimental evaluation of any resuscitation therapy should account for the degree of preexisting physiological compromise before therapy is initiated.
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Affiliation(s)
- Penny S Reynolds
- Departments of Emergency Medicine, Virginia Commonwealth University Reanimation Engineering Shock Center, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0401, USA.
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Hirshberg A, Hoyt DB, Mattox KL. From “Leaky Buckets” to Vascular Injuries: Understanding Models of Uncontrolled Hemorrhage. J Am Coll Surg 2007; 204:665-72. [PMID: 17382227 DOI: 10.1016/j.jamcollsurg.2007.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Revised: 12/17/2006] [Accepted: 01/02/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Asher Hirshberg
- Department of Surgery, Kings County Hospital Center and SUNY Downstate College of Medicine, Brooklyn, NY 11203, USA.
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Suárez-Peláez J, Burillo-Putze G, Lubillo-Montenegro S, Ramos-Gómez L. Pre-hospital fluid therapy in the critically injured patient: need for clinical studies. Injury 2007; 38:130-1; author reply 131-2. [PMID: 16996064 DOI: 10.1016/j.injury.2006.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 05/25/2006] [Indexed: 02/02/2023]
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Spahn DR, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Gordini G, Stahel PF, Hunt BJ, Komadina R, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R. Management of bleeding following major trauma: a European guideline. Crit Care 2007; 11:R17. [PMID: 17298665 PMCID: PMC2151863 DOI: 10.1186/cc5686] [Citation(s) in RCA: 303] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 01/08/2007] [Accepted: 02/13/2007] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes. METHODS The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature. RESULTS Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient. CONCLUSION A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.
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Affiliation(s)
- Donat R Spahn
- Department of Anesthesiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Vladimir Cerny
- Charles University in Prague, Faculty of Medicine in Hradec Králové, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Sokolska 581, 50005 Hradec Králové, Czech Republic
| | - Timothy J Coats
- Leicester Royal Infirmary, Accident and Emergency Department, Infirmary Square, Leicester LE1 5WW, UK
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, University of Paris XI Faculté de Médecine Paris-Sud, 63 rue Gabriel Péri, 94276 Le Kremlin-Bicêtre, France
| | - Enrique Fernández-Mondéjar
- Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves, ctra de Jaén s/n, 18013 Granada, Spain
| | - Giovanni Gordini
- Department of Anaesthesia and Intensive Care, Ospedale Maggiore, Largo Nigrisoli 2, 40100 Bologna, Italy
| | - Philip F Stahel
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Medical School, 777 Bannock Street, Denver, CO 80204, USA
| | - Beverley J Hunt
- Departments of Haematology, Pathology and Rheumatology, Guy's & St Thomas' Foundation Trust, Lambeth Palace Road, London SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, 3000 Celje, Slovenia
| | - Edmund Neugebauer
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimerstrasse 200, 51109 Köln (Merheim), Germany
| | - Yves Ozier
- Department of Anaesthesia and Intensive Care, Université René Descartes Paris 5, AP-HP, Hopital Cochin, 27 rue du Fbg Saint-Jacques, 75014 Paris, France
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, University of Brussels, Belgium, route de Lennik 808, 1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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