Crystalloid-based Resuscitation Research Articles

Огляд рекомендацій з інтенсивної терапії гострої масивної крововтрати в акушерстві

У статті подано сучасні рекомендації з інтенсивної терапії гострої крововтрати в акушерстві. Акушерські кровотечі залишаються провідною причиною материнської смертності в усьому світі. Нові стратегії лікування кровотеч передбачають використання гемостатичної реанімації з визначенням оптимального співвідношення для введення різних компонентів і препаратів крові. Масивні протоколи трансфузії рекомендують раннє використання продуктів крові й обмежують традиційний підхід ранньої масивної інфузійної терапії на основі кристалоїдів. За останні кілька років змінилися дані про гемостатичну реанімацію, і тепер ведуться обговорення щодо оптимальних стратегій інфузійно-трансфузійної терапії. Використання транексамової кислоти, концентрату фібриногену і концентрату протромбінового комплексу стало потенційно новою альтернативною стратегією лікування з поліпшеними профілями безпеки.

510 A Case-controlled Retrospective Review of Fluid Resuscitation in Patients with Concomitant Burn and Trauma Injuries

Abstract Introduction Aggressive fluid resuscitation with crystalloid has been a mainstay of therapy in burn injuries for over 50 years. However, in trauma populations there has been a shift away from crystalloid based resuscitation and the early administration of blood products has been recommended. The primary objective of this study was to evaluate if large-volume crystalloid resuscitation of patients presenting with both burn and trauma injuries is associated with higher mortality and complications. Methods This was a matched case-controlled retrospective chart review of patients treated over a 5-year period that suffered mixed burn and trauma injuries (MI). Patients that suffered burn only injuries (BO) were used as the control and were matched on TBSA, age, and gender. All patients were resuscitated using the standard burn center resuscitation protocol. Results A total of 4,416 patients were admitted to the burn center during the study period. Of those 18 had concomitant burn and trauma injuries requiring burn fluid resuscitation and were successfully matched to BO patients. There was no difference in age, gender, ethnicity, % TBSA burned, presence of inhalation injury, or Injury Severity Score (ISS). BO patients were more likely to have flame/flash as the etiology of burn injury (p=.0257). With fluid resuscitation, there was no difference in the total volume of fluid administered, or the amount of crystalloid or colloid administered. MI patients were more likely to have received blood products than BO patients (472 ml vs 19 ml, p=.0387). There was no difference in the following outcome measures: mortality, ICU days, ventilator days, number of surgeries, infections, or major complications. The only significant outcome difference was that the BO patients had a greater hospital length of stay (44 days) than the MI patients (24 days, p < 0.001). Conclusions Aggressive fluid resuscitation using existing burn resuscitation protocols did not result in greater complications in burn-trauma patients than in burn only patients. Crystalloid-based burn resuscitation is safe in patients with combined burn and trauma injuries.

Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes

Both military and civilian clinical practice guidelines include early plasma transfusion to achieve a plasma to red cell ratio approaching 1:1 to 1:2. However, it was not known how early plasma should be given for optimal benefit. Two recent randomized clinical trials were published, with apparently contradictory results. The Prehospital Air Medical Plasma (PAMPer) clinical trial showed a nearly 30% reduction in mortality with plasma transfusion in the prehospital environment, while the Control of Major Bleeding After Trauma (COMBAT) clinical trial showed no survival improvement. To facilitate a post hoc combined analysis of the COMBAT and PAMPer trials to examine questions that could not be answered by either clinical trial alone. We hypothesized that prehospital transport time influenced the effects of prehospital plasma on 28-day mortality. A total of 626 patients in the 2 clinical trials were included. Patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 U of thawed plasma followed by standard care in the prehospital environment. Data analysis was performed between September 2018 and January 2019. Prehospital transfusion of 2 U of plasma compared with crystalloid-based resuscitation. The main outcome was 28-day mortality. In this post hoc analysis of 626 patients (467 men [74.6%] and 159 women [25.4%]; median [interquartile range] age, 42 [27-57] years) who had trauma with hemorrhagic shock, a Cox regression analysis showed a significant overall survival benefit for plasma (hazard ratio [HR], 0.65; 95% CI, 0.47-0.90; P = .01) after adjustment for injury severity, age, and clinical trial cohort (COMBAT or PAMPer). A significant association with prehospital transport time was detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than 20 minutes (HR, 2.12; 95% CI, 1.05-4.30; P = .04), while increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40-1.51; P = .46). No serious adverse events were associated with prehospital plasma transfusion. These data suggest that prehospital plasma is associated with a survival benefit when transport times are longer than 20 minutes and that the benefit-risk ratio is favorable for use of prehospital plasma. ClinicalTrials.gov identifiers: NCT01838863 (COMBAT) and NCT01818427 (PAMPer).

Thoracic Injuries and Management Options

Thoracic trauma accounts for nearly 25% of deaths secondary to blunt trauma. The most common chest injury is a rib fracture, which can be associated with a mortality risk as high as 35%. Other injuries include pneumothorax, hemothorax, esophageal injury, aortic transection, blunt cardiac injury, tracheobronchial disruption, and pulmonary contusion. The majority of thoracic injuries can be treated successfully with either observation or tube thoracostomy and general supportive care alone. Independent contributors to mortality include inadequate pain control, poor pulmonary hygiene, failure to intubate appropriately, and excessive crystalloid-based resuscitation. This review contains 3 figures, 5 tables and 64 references Key words: aorta, bronchus, esophagus, hemothorax, pneumothorax, pulmonary contusion, rib fracture, thoracic, trachea, tracheobronchial

The need for optimized crystalloid-based resuscitation.

The need for optimized crystalloid-based resuscitation.

An update on the use of massive transfusion protocols in obstetrics

Obstetrical hemorrhage remains a leading cause of maternal mortality worldwide. New concepts involving the pathophysiology of hemorrhage have been described and include early activation of both the protein C and fibrinolytic pathways. New strategies in hemorrhage treatment include the use of hemostatic resuscitation, although the optimal ratio to administer the various blood products is still unknown. Massive transfusion protocols involve the early utilization of blood products and limit the traditional approach of early massive crystalloid-based resuscitation. The evidence behind hemostatic resuscitation has changed in the last few years, and debate is ongoing regarding optimal transfusion strategies. The use of tranexamic acid, fibrinogen concentrates, and prothrombin complex concentrates has emerged as new potential alternative treatment strategies with improved safety profiles.

Application of the Berlin definition in PROMMTT patients

Acute lung injury following trauma resuscitation remains a concern despite recent advances. With the use of the PROMMTT study population, the risk of hypoxemia and potential modifiable risk factors are studied. Patients with survival for 24 hours or greater with at least one intensive care unit day were included in the analysis. Hypoxemia was categorized using the Berlin definition for adult respiratory distress syndrome: none (PaO₂-to-FIO₂ ratio [P/F] > 300 mm Hg), mild (P/F, 201-300 mm Hg), moderate (P/F, 101-200 mm Hg) or severe (P/F ≤ 100 mm Hg). The cohort was dichotomized into those with none or mild hypoxemia and those with moderate or severe injury. Early resuscitation was defined as that occurring 0 hour to 6 hours from arrival; late resuscitation was defined as that occurring 7 hours to 24 hours. Multivariate logistic regression models were developed controlling for age, sex, mechanisms of injury, arrival physiology, individual Abbreviated Injury Scale (AIS) scores, blood transfusions, and crystalloid administration. Of the patients 58.7% (731 of 1,245) met inclusion criteria. Hypoxemia occurred in 69% (mild, 24%; moderate, 28%; severe, 17%). Mortality was highest (24%) in the severe group. During early resuscitation (0-6 h), logistic regression revealed age (odd ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.04), chest AIS score (OR, 1.31; 95% CI, 1.10-1.57), and intravenously administered crystalloid fluids given in 500 mL increments (OR, 1.12; 95% CI, 1.01-1.25) as predictive of moderate or severe hypoxemia. During late resuscitation, age (OR, 1.02; 95% CI, 1.00-1.04), chest AIS score (OR, 1.33; 95% CI, 1.11-1.59), and crystalloids given during this period (OR, 1.05; 95% CI, 1.01-1.10) were also predictive of moderate-to-severe hypoxemia. Red blood cell, plasma, and platelet transfusions (whether received during early or late resuscitation) failed to demonstrate an increased risk of developing moderate/severe hypoxemia. Severe chest injury, increasing age, and crystalloid-based resuscitation, but not blood transfusions, were associated with increased risk of developing moderate-to-severe hypoxemia following injury.

Intraoperative fluid losses revisited

SUMMARY Intravenous fluid therapy is an essential element of surgical procedures. However, consensus regarding the optimal volume and composition of fluid is still lacking. Despite increasing evidence that aggressive crystalloid-based resuscitation is associated with several complications large volumes are still used peroperatively. The aim of this paper is to investigate the pathophysiology behind fluid losses and how to best administer peroperative fluids in appropriate amounts.

Resuscitation volume and multiple organ dysfunction syndrome

Patients with severe infections and major trauma often develop multiple organ dysfunction syndrome (MODS). Aggressive fluid resuscitation can be involved in such a process and several lines of evidence have demonstrated the detrimental effects of large crystalloid-based resuscitation strategies on MODS. Additionally, fluid-restrictive strategies have been associated with a decreased frequency of acute respiratory distress syndrome (and a shorter time to recover from it) and with trends toward a shorter length of hospital stay and lower mortality. Recent knowledge of the pathophysiology of septic shock and severe trauma indicates that a release of inflammatory mediators occurs early in the course of the disease. These mediators, especially pro-inflammatory cytokines as well as hypopituitary adrenal axis dysfunction, are involved in cardiac dysfunction and vasodilatation-induced hypotension. Taking into account this combination of severe inflammation and secondary changes in endocrine profile through an ear...

HYPERTONIC SALINE MODULATION OF INTESTINAL TISSUE STRESS AND FLUID BALANCE

Crystalloid-based resuscitation of severely injured trauma patients leads to intestinal edema. A potential mechanism of intestinal edema-induced ileus is a reduction of myosin light chain phosphorylation in intestinal smooth muscle. We sought to determine if the onset of edema initiated a measurable, early mechanotransductive signal and if hypertonic saline (HS) can modulate this early signal by changing intestinal fluid balance. An anesthetized rat model of acute interstitial intestinal edema was used. At laparotomy, the mesenteric lymphatic was cannulated to measure lymph flow and pressure, and a fluid-filled micropipette was placed in the intestinal submucosa to measure interstitial pressure. Rats were randomized into four groups (n=6 per group): sham, mesenteric venous hypertension+80 mL/kg 0.9% isotonic sodium chloride solution (ISCS 80), mesenteric venous hypertension+80 mL/kg 0.9% ISCS+4 mL/kg 7.5% saline (ISCS 80+HS), or 4 mL/kg 7.5% saline (HS alone) to receive the aforementioned intravenous fluid administered over 5 min. Measurements were made 30 min after completion of the preparation. Tissue water, lymph flow, and interstitial pressure were measured. Resultant applied volume induced stress on the smooth muscle (sigmaravi-muscularis) was calculated. Mesenteric venous hypertension and crystalloid resuscitation caused intestinal edema that was prevented by HS. Intestinal edema caused an early increase in intestinal interstitial pressure that was prevented by HS. Hypertonic saline did not augment lymphatic removal of intestinal edema. sigmaravi-muscularis was increased with onset of edema and prevented by HS, paralleling the interstitial pressure data. Intestinal edema causes an early increase in interstitial pressure that is prevented by HS. Prevention of the edema-induced increase in interstitial pressure serves to blunt the mechanotransductive signal of sigmaravi-muscularis.

THE CELLULAR, METABOLIC, AND SYSTEMIC CONSEQUENCES OF AGGRESSIVE FLUID RESUSCITATION STRATEGIES

Increasing evidence has demonstrated that aggressive crystalloid-based resuscitation strategies are associated with cardiac and pulmonary complications, gastrointestinal dysmotility, coagulation disturbances, and immunological and inflammatory mediator dysfunction. As large volumes of fluids are administered, imbalances in intracellular and extracellular osmolarity occur. Disturbances in cell volume disrupt numerous regulatory mechanisms responsible for keeping the inflammatory cascade under control. Several authors have demonstrated the detrimental effects of large, crystalloid-based resuscitation strategies on pulmonary complications in specific surgical populations. Additionally, fluid-restrictive strategies have been associated with a decreased frequency of and shorter time to recovery from acute respiratory distress syndrome and trends toward shorter lengths of stay and lower mortality. Early resuscitation of hemorrhagic shock with predominately saline-based regimens has been associated with cardiac dysfunction and lower cardiac output, as well as higher mortality. Numerous investigators have evaluated potential risk factors for developing abdominal compartment syndrome and have universally noted the excessive use of crystalloids as the primary determinant. Resuscitation regimens that cause early increases in blood flow and pressure may result in greater hemorrhage and mortality than those regimens that yield comparable flow and pressure increases late in resuscitation. Future resuscitation research is likely to focus on improvements in fluid composition and adjuncts to administration of large volume of fluid.