Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions.
01 Jul 2002-Acta Anaesthesiologica Scandinavica (Munksgaard International Publishers)-Vol. 46, Iss: 6, pp 625-638
TL;DR: A small‐volume resuscitatioin using hypertonic solutions encompasses the rapid infusion of a small dose of 7.2–7.5% NaCl/colloid solution for initial therapy of severe hypovolemia and shock associated with trauma.
Abstract: Background: The concept of small-volume resuscitatioin (SVR) using hypertonic solutions encompasses the rapid infusion of a small dose (4 ml per kg body weight, i.e. approximately 250 ml in an adult patient) of 7.2–7.5% NaCl/colloid solution. Originally, SVR was aimed for initial therapy of severe hypovolemia and shock associated with trauma.
Methods: The present review focusses on the findings concerning the working mechanisms responsible for the rapid onset of the circulatory effect, the impact of the colloid component on microcirculatory resuscitation, and describes the indications for its application in the preclinical scenario as well as perioperatively and in intensive care medicine.
Results: With respect to the actual data base of clinical trials SVR seems to be superior to conventional volume therapy with regard to faster normalization of microvascular perfusion during shock phases and early resumption of organ function. Particularly patients with head trauma in association with systemic hypotension appear to benefit. Besides, potential indications for this concept include cardiac and cardiovascular surgery (attenuation of reperfusion injury during declamping phase) and burn injury. The review also describes disadvantaages and potential adverse effects of SVR:
Conclusion: Small-volume resuscitation by means of hypertonic NaCl/colloid solutions stands for one of the most innovative concepts for primary resuscitation from trauma and shock established in the past decade. Today the spectrum of potential indications envolves not only prehospital trauma care, but also perioperative and intensive care therapy.
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TL;DR: This first human trial evaluating the immunologic/anti-inflammatory effects of hypertonic resuscitation in trauma patients demonstrates that HSD promotes a more balanced inflammatory response to hemorrhagic shock, raising the possibility that similar to experimental models, HSD might also attenuate post-trauma MOD.
Abstract: Hemorrhagic shock following civilian trauma is an important contributor to the morbidity and mortality in this patient population.1 The body's early response to traumatic injury and hemorrhage is characterized by an excessive innate immune activation and by an overwhelming inflammatory reaction.2 Research findings suggest a strong link between immune dysfunction and post-traumatic complications such as multiorgan dysfunction (MOD) and sepsis.3–5 Regulated inflammatory responses are generally considered a beneficial host response to injury,6 while post-traumatic hyperinflammation and ensuing immune incompetence are considered to be maladaptive and often auto-destructive.2
One of the fundamental principles applied to the management of hemorrhagic shock is the early administration of fluid and blood products to correct the deranged hemodynamic status. Crystalloid solutions have generally been considered first-line therapy. However, recent evidence suggests that isotonic crystalloid solutions may actually aggravate the immune dysfunction.7 By contrast, a number of experimental studies reveal that hypertonic solutions have favorable immunomodulatory effects on hemorrhage/resuscitation-induced leukocyte activation.4,8–11 For example, data derived from both in vitro human leukocyte studies as well as animal models of hemorrhagic shock found that hypertonicity decreases neutrophil activation/adherence,12–16 stimulates lymphocyte proliferation,17 inhibits pro-inflammatory but stimulates anti-inflammatory cytokine production by monocyte/macrophages,8,18–22 and reduces hormone secretion.23,24 In the in vivo setting, hypertonic saline resuscitation strategies have been shown to mitigate the development of inflammation. When considered in conjunction with the ability of small-volume (4 mL/kg) infusion of hypertonic saline, to restore mean arterial pressure and microvascular perfusion25,26 as well as its proven safety record in patients,27,28 there has been renewed interest in the use of hypertonic saline solutions, with or without dextran in the management of patients with hemorrhagic shock.29–31 One critical piece of information lacking in the translation of these beneficial effects to the human trauma setting is whether hypertonic saline/hypertonic saline dextran (HS/HSD) is able to exert comparable immunologic effects in humans.
The major objective of the present studies was to investigate the immunomodulatory effects of HSD in patients sustaining hemorrhagic shock following trauma. Without altering standards of treatment, patients were randomized to receive either a single 250-mL bolus of HSD or placebo. Blood drawn at subsequent time points was evaluated for a number of cellular and molecular inflammatory markers known to be altered by shock/resuscitation. We hypothesized that these markers would be altered in resuscitated trauma patients, in a manner previously reported in experimental models. These data were intended to provide “proof of principle” for larger trials that intended to study clinical outcomes with this resuscitation regimen.
197 citations
TL;DR: The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide.
Abstract: Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations 'permissive hypotension' may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing 'blind' transfusion or 'damage control resuscitation', a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.
184 citations
Cites background from "Small-volume resuscitation: from ex..."
...hypovolaemia and shock, generally seen after severe trauma and haemorrhage.(73) Use of hypertonic fluids in the field is advocated...
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TL;DR: Treatment recommendations for veterinary TBI patients are primarily based on human and experimental studies and personal experience, andTherapeutic guidelines have been developed that center on maintaining adequate cerebral perfusion.
Abstract: Objective – To review current information regarding the pathophysiology associated with traumatic brain injury (TBI), and to outline appropriate patient assessment, diagnostic, and therapeutic options.
Etiology – TBI in veterinary patients can occur subsequent to trauma induced by motor vehicle accidents, falls, and crush injuries. Primary brain injury occurs at the time of initial impact as a result of direct mechanical damage. Secondary brain injury occurs in the minutes to days following the trauma as a result of systemic extracranial events and intracranial changes.
Diagnosis – The initial diagnosis is often made based on history and physical examination. Assessment should focus on the cardiovascular and respiratory systems followed by a complete neurologic examination. Advanced imaging may be indicated in a patient that fails to respond to appropriate medical therapy.
Therapy – Primary brain injury is beyond the control of the veterinarian. Therefore, treatment should focus on minimizing the incidence or impact of secondary brain injury. Because of a lack of prospective or retrospective clinical data, treatment recommendations for veterinary TBI patients are primarily based on human and experimental studies and personal experience. Therapeutic guidelines have been developed that center on maintaining adequate cerebral perfusion.
Prognosis – Severe head trauma is associated with high mortality in humans and animals. However, dogs and cats have a remarkable ability to compensate for loss of cerebral tissue. It is therefore important not to reach hasty prognostic conclusions based on initial appearance. Many pets go on to have a functional outcome and recover from injury.
127 citations
TL;DR: The origins of perioperative fluid management in children, the current options for crystalloid fluid management, and the current information on colloid use in pediatric patients are discussed.
Abstract: It has been more than 50 yr since the landmark article in which Holliday and Segar (Pediatrics 1957;19:823-32) proposed the rate and composition of parenteral maintenance fluids for hospitalized children. Much of our practice of fluid administration in the perioperative period is based on this article. The glucose, electrolyte, and intravascular volume requirements of the pediatric surgical patient may be quite different than the original population described, and consequently, use of traditional hypotonic fluids proposed by Holliday and Segar may cause complications, such as hyperglycemia and hyponatremia, in the postoperative surgical patient. There is significant controversy regarding the choice of isotonic versus hypotonic fluids in the postoperative period. We discuss the origins of perioperative fluid management in children, review the current options for crystalloid fluid management, and present information on colloid use in pediatric patients.
122 citations
Cites background from "Small-volume resuscitation: from ex..."
...These solutions are only given in small amounts (4 mL/kg) because of their hypertonicity, but are able to improve preload and thereby cardiac output.(120,121)...
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TL;DR: Network for clinical studies in SCI patients should be established, as a basic requirement for further improvement in outcome in such patients, because it is not known whether therapeutic hypothermia or any further pharmacological intervention has beneficial effects or not.
109 citations
Cites methods from "Small-volume resuscitation: from ex..."
...The concept of “small-volume resuscitation” (SVR) uses hypertonic– hyperosmotic solutions and to provide the initial therapy for severe hypovolaemia and shock associated with trauma [ 39 ]....
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References
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Book•
14 Mar 1995
TL;DR: This yearbook compiles the most recent developments in experimental and clinical research and practice in one comprehensive reference book for intensive care and emergency medicine.
Abstract: This yearbook compiles the most recent developments in experimental and clinical research and practice in one comprehensive reference book. The chapters are written by well recognized experts in the field of intensive care and emergency medicine. It is addressed to everyone involved in internal medicine, anesthesia, surgery, pediatrics, intensive care and emergency medicine.
892 citations
TL;DR: The relationship between raised intracranial pressure (ICP), hypotension, and outcome from severe head injury is described and a stepwise ordinal logistic regression was used to determine outcome.
Abstract: ✓ This study describes the relationship between raised intracranial pressure (ICP), hypotension, and outcome from severe head injury. The study is based on information derived from the Traumatic Coma Data Bank where ICP records from a relatively large number of patients were available to help delineate the major factors influencing outcome. From the total data base of 1030 patients, 428 met minimum monitoring duration criteria for inclusion in the present analysis. Outcome was classified according to the Glasgow Outcome Scale score determined at 6 months postinjury. Arrays of comparably defined summary measures describing the patient's course were considered for ICP, blood pressure (BP), central perfusion pressure, and therapy intensity level. For instance, the array of ICP summary descriptors included the proportion of ICP readings greater than x, for x = 0 to 80 mm Hg by increments of 5 mm Hg. A total of 187 candidate summary descriptors were considered. A stepwise ordinal logistic regression was used t...
751 citations
"Small-volume resuscitation: from ex..." refers background in this paper
...from severe head trauma is strongly related to elevated intracranial pressure and hypotension (43)....
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TL;DR: The hypothesis that neutrophils, which accumulate in the mucosa in response to xanthine oxidase activation, mediate the oxyradical-dependent injury produced by reperfusion of the ischemic bowel is supported.
Abstract: Recent studies indicate that polymorphonuclear neutrophils (PMNs) infiltrate the intestinal mucosa during ischemia and after reperfusion. To determine whether PMNs mediate the increased microvascular permeability produced by ischemia-reperfusion (I/R) we treated cats with either saline, antineutrophil serum (ANS), or a monoclonal antibody specific for the beta-chain of the CD18 complex (MoAb 60.3) that prevents neutrophil adherence and extravasation. Intestinal microvascular permeability to plasma proteins was measured in control preparations (0.08 +/- 0.007), in preparations subjected to 1 h of ischemia then reperfusion (I/R, 0.32 +/- 0.02), I/R preparations treated with ANS (0.13 +/- 0.01), and I/R preparations treated with MoAb (0.12 +/- 0.003). Our results indicate that both PMN depletion (to less than 10% control) and prevention of PMN adherence significantly attenuate the increased microvascular permeability induced by I/R. These findings, coupled to previous results obtained from this model, support the hypothesis that neutrophils, which accumulate in the mucosa in response to xanthine oxidase activation, mediate the oxyradical-dependent injury produced by reperfusion of the ischemic bowel.
738 citations
"Small-volume resuscitation: from ex..." refers background in this paper
...Chemotactic accumulation of circulating leukocytes and their adhesion to the endothelial lining of postcapillary venules have long been recognized as key features of postischemic reperfusion injury (23,24)....
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TL;DR: Infusion of 0.9% saline, but not lactated Ringer's solution, caused a metabolic acidosis with hyperchloremia and a concomitant decrease in the strong ion difference and the amount of weak plasma acid.
Abstract: Background Changes in acid-base balance caused by infusion of a 0.9% saline solution during anesthesia and surgery are poorly characterized. Therefore, the authors evaluated these phenomena in a dose-response study. Methods Two groups of 12 patients each who were undergoing major intraabdominal gynecologic surgery were assigned randomly to receive 0.9% saline or lactated Ringer's solution in a dosage of 30 ml x kg(-1) x h(-1). The pH, arterial carbon dioxide tension, and serum concentrations of sodium, potassium, chloride, lactate, and total protein were measured in 30-min intervals. The serum bicarbonate concentration was calculated using the Henderson-Hasselbalch equation and also using the Stewart approach from the strong ion difference and the amount of weak plasma acid. The strong ion difference was calculated as serum sodium + serum potassium - serum chloride - serum lactate. The amount of weak plasma acid was calculated as the serum total protein concentration in g/dl x 2.43. Results Infusion of 0.9% saline, but not lactated Ringer's solution, caused a metabolic acidosis with hyperchloremia and a concomitant decrease in the strong ion difference. Calculating the serum bicarbonate concentration using the Henderson-Hasselbalch equation or the Stewart approach produced equivalent results. Conclusions Infusion of approximately 30 ml x kg(-1) x h(-1) saline during anesthesia and surgery inevitably leads to metabolic acidosis, which is not observed after administration of lactated Ringer's solution. The acidosis is associated with hyperchloremia.
699 citations
"Small-volume resuscitation: from ex..." refers background in this paper
...5% NaCl/4–6% dextran 70 and in 8/51 patients of the control group receiving Ringer’s lactate (50)....
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...(50) has demonstrated that infusion of approximately 30 ml/kg/h saline (total amount 70 ml/kg b....
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TL;DR: 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.
Abstract: 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.
439 citations
"Small-volume resuscitation: from ex..." refers background in this paper
...multicenter trial on prehospital hypertonic saline/dextran infusion for posttraumatic hypotension yielded positive results (6)....
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...Prehospital trials in particular have shown favorable results in cases of severe trauma requiring immediate surgery (6)....
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...In prehospital trials, small-volume resuscitation by means of hypertonic saline colloid solutions has shown favorable results in hypotensive trauma patients (5); both in cases of severe trauma requiring immediate surgery (6) and in patients...
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...Serum osmolality decreased within the first 4–8 h after bolus infusion, and after 24 h there was no difference between those patients having received hypertonic saline and the control group (6,49)....
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...In a controlled clinical study in trauma patients mean serum sodium concentration was 9 mEq/l higher in the treatment group as compared to the control group at the time of arrival in the emergency room (6)....
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