https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)02689-1.pdf

Traumatic brain injury.

‘This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2004, Issue 4. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.’ Roberts, I., Alderson, P., Bunn, F., Chinnock, P., Ker, K., Schierhout, G. 'Colloids versus crystalloids for fluid resuscitation in critically ill patients' Cochrane Database of Systematic Reviews 2004 (4) CD000567. DOI:10.1002/14651858.CD000567.pub2

/pdf/colloids-versus-crystalloids-for-fluid-resuscitation-in-58xrgop16t.pdf

Colloids versus crystalloids for fluid resuscitation in critically ill patients

This review addresses the pathophysiology and treatment of hemorrhagic shock – a condition produced by rapid and significant loss of intravascular volume, which may lead sequentially to hemodynamic instability, decreases in oxygen delivery, decreased tissue perfusion, cellular hypoxia, organ damage, and death. Hemorrhagic shock can be rapidly fatal. The primary goals are to stop the bleeding and to restore circulating blood volume. Resuscitation may well depend on the estimated severity of hemorrhage. It now appears that patients with moderate hypotension from bleeding may benefit by delaying massive fluid resuscitation until they reach a definitive care facility. On the other hand, the use of intravenous fluids, crystalloids or colloids, and blood products can be life saving in those patients who are in severe hemorrhagic shock. The optimal method of resuscitation has not been clearly established. A hemoglobin level of 7–8 g/dl appears to be an appropriate threshold for transfusion in critically ill patients with no evidence of tissue hypoxia. However, maintaining a higher hemoglobin level of 10 g/dl is a reasonable goal in actively bleeding patients, the elderly, or individuals who are at risk for myocardial infarction. Moreover, hemoglobin concentration should not be the only therapeutic guide in actively bleeding patients. Instead, therapy should be aimed at restoring intravascular volume and adequate hemodynamic parameters.

/pdf/clinical-review-hemorrhagic-shock-5bjpy8tp8m.pdf

Clinical review: hemorrhagic shock.

ContextSevere, uncompensated, traumatic hemorrhagic shock causes significant
morbidity and mortality, but resuscitation with an oxygen-carrying fluid might
improve patient outcomes.ObjectiveTo determine if the infusion of up to 1000 mL of diaspirin cross-linked
hemoglobin (DCLHb) during the initial hospital resuscitation could reduce
28-day mortality in traumatic hemorrhagic shock patients.Design and SettingMulticenter, randomized, controlled, single-blinded efficacy trial conducted
between February 1997 and January 1998 at 18 US trauma centers selected for
their high volume of critically injured trauma patients, but 1 did not enroll
patients.PatientsA total of 112 patients with traumatic hemorrhagic shock and unstable
vital signs or a critical base deficit, who had a mean (SD) patient age of
39 (20) years. Of the infused patients, 79% were male and 56% were white.
An exception to informed consent was used when necessary.InterventionAll patients were to be infused with 500 mL of DCLHb or saline solution.
Critically ill patients who still met entry criteria could have received up
to an additional 500 mL during the 1-hour infusion period.Main Outcome MeasuresTwenty-eight day mortality, 28-day morbidity, 48-hour mortality, and
24-hour lactate levels.ResultsOf the 112 patients, 98 (88%) were infused with DCLHb or saline solution.
At 28 days, 24 (46%) of the 52 patients infused with DCLHb died, and 8 (17%)
of the 46 patients infused with the saline solution died (P = .003). At 48 hours, 20 (38%) of the 52 patients infused with DCLHb
died and 7 (15%) of the 46 patients infused with the saline solution died
(P = .01). The 28-day morbidity rate, as measured
by the multiple organ dysfunction score, was 72% higher in the DCLHb group
(P = .03). There was no difference in adverse event
rates or the 24-hour lactate levels.ConclusionsMortality was higher for patients treated with DCLHb. Although further
analysis should investigate whether the mortality difference was solely due
to a direct treatment effect or to other factors, DCLHb does not appear to
be an effective resuscitation fluid.

https://jamanetwork.com/journals/jama/articlepdf/192107/JOC91232.pdf

Diaspirin Cross-Linked Hemoglobin (DCLHb) in the Treatment of Severe Traumatic Hemorrhagic Shock: A Randomized Controlled Efficacy Trial

The administration of IV fluid to avoid dehydration, maintain an effective circulating volume, and prevent inadequate tissue perfusion should be considered, along with the maintenance of sleep, pain relief, and muscular relaxation, a core element of the perioperative practice of anesthesia. Knowledge of the effects of different fluids has increased in recent years, and the choice of fluid type in a variety of clinical situations can now be rationally guided by an understanding of the physicochemical and biological properties of the various crystalloid and colloid solutions available. However, there are few useful clinical outcome data to guide this decision. Deciding how much fluid to give has historically been more controversial than choosing which fluid to use. A number of clinical studies support the notion that an approach based on administering fluids to achieve maximal left ventricular stroke volume (while avoiding excess fluid administration and consequent impairment of left ventricular performance) may improve outcomes. In this article, we review the available fluid types and strategies of fluid administration and discuss their relationship to clinical outcomes in adults.

Perioperative fluid management and clinical outcomes in adults.

The safety and efficacy of 7.5% sodium chloride in 6% dextran 70 (HSD) in posttraumatic hypotension was evaluated in Houston, Denver, and Milwaukee. Multicentered, blinded, prospective randomized studies were developed comparing 250 mL of HSD versus 250 mL of normal crystalloid solution administered before routine prehospital and emergency center resuscitation. During a 13-month period, 422 patients were enrolled, 211 of whom subsequently underwent operative procedures. Three hundred fifty-nine patients met criteria for efficacy analysis, 51% of whom were in the HSD group. Seventy-two per cent of all patients were victims of penetrating trauma. The mean injury severity score (19), Trauma Score plus Injury Severity Score (TRISS) probability of survival, revised trauma scores (5.9), age, ambulance times, preinfusion blood pressure, and etiology distribution were identical between groups. The total amount of fluid administered, white blood cell count, arterial blood gases, potassium, or bicarbonate also were identical between groups. The HSD group had an improved blood pressure (p = 0.024). Hematocrit, sodium chloride, and osmolality levels were significantly elevated in the Emergency Center. Although no difference in overall survival was demonstrated, the HSD group requiring surgery did have a better survival (p = 0.02), with some variance among centers. The HSD group had fewer complications that the standard treatment group (7 versus 24). A greater incidence of adult respiratory distress syndrome, renal failure, and coagulopathy occurred in the standard treatment group. No anaphylactoid nor Dextran-related coagulopathies occurred in the HSD group. Although this trial demonstrated trends supportive of HSD in hypotensive hemorrhagic shock patients requiring surgery, a larger sample size will be required to establish which subgroups of trauma patients might maximally benefit from the prehospital use of a small volume of hyperosmolar solution. This study demonstrates the safety of administering 250 mL 7.5% HDS to this group of patients.

Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial.

We report the results of the first clinical study on the use of a hypertonic saline-dextran solution for the prehospital management of hypotensive victims of penetrating trauma. During a 4-month period, 48 trauma patients with penetrating injuries and a prehospital systolic blood pressure of 90 mm Hg or less were infused in-field with 250 ml of either a hypertonic saline-dextran solution or the crystalloid plasmalyte A. There were no complications associated with the infusion of the hypertonic saline-dextran solution, and execution of the protocol by paramedic personnel was both safe and uniformly successful. The potential impact of this solution on medical care and the results of this feasibility study justify the initiation of a larger prospective, randomized clinical trial on the efficacy of this solution in the prehospital setting.

Peter A. Maningas

Papers

Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial.

Hypertonic Saline-Dextran Solutions for the Prehospital Management of Traumatic Hypotension

Hypertonic Saline-Dextran Solutions for the Prehospital Management of Traumatic Hypotension