Fluid Resuscitation In Patients Research Articles

415 Time Is of the Essence: Early Intravenous Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock

415 Time Is of the Essence: Early Intravenous Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock

Efficacies of fluid resuscitation as guided by lactate clearance rate and central venous oxygen saturation in patients with septic shock

To estimate the efficacies of fluid resuscitations as guided by lactate clearance rate (LC) and central venous oxygen saturation (ScvO₂) in patients with septic shock. 100 patients diagnosed with septic shock from June 2012 to June 2014 in department of critical care medicine of sixteen hospitals were enrolled. They were randomly divided into two groups of study and control (each n = 50). After a diagnosis of sepsis shock, they were treated symptomatically timely and fluid resuscitation was started as early as possible according to the 2008 Guideline for Managing Sepsis & Septic Shock. Central venous pressure (CVP) ≥ 8 mmHg (1 mmHg = 0.133 kPa), mean arterial pressure (MAP) ≥ 65 mmHg, urine output ≥ 0.5 ml × kg⁻¹ × h⁻¹, ScvO₂≥ 70% and LC ≥ 10% (or lactate ≤ 2.0 mmol) served as target values for fluid resuscitation therapy in study group versus CVP ≥ 8 mmHg, MAP ≥ 65 mmHg, urine output ≥ 0.5 ml × kg⁻¹ × h⁻¹ and ScvO₂≥ 70% in control group. The general conditions and clinical characteristics, changes in CVP, MAP, urine output, ScvO₂, lactate level and/or LC before (0 hour) and every hour (1-6 h) after the start of fluid resuscitation and other related outcome indicators were recorded. No significant difference existed in general data. The 28-day mortality was 40% for study group versus 56% for control group. There was no significant inter-group difference (P > 0.05). The time of mechanical ventilation and length of intensive care unit (ICU) stay were lower in study group than those in control group [mechanical ventilation time (11.200 ± 17.069) vs (15.760 ± 14.215), P = 0.150; length of ICU stay (13.240 ± 17.127) vs (23.980 ± 18.298), P = 0.003]. The 28-day mortality was independently associated with LC and ScvO₂reaching target values for fluid resuscitation in study group (χ² = 10.930, P = 0.001) while the 28-day mortality was independently associated with ScvO₂reaching target value for fluid resuscitation in control group (χ² = 6.395, P = 0.011). Among all patients, the 28-day mortality was independently associated with ScvO₂reaching target value for fluid resuscitation (χ² = 14.530, P = 0.000), but not LC (χ² = 1.175, P = 0.278). A combination of LC and ScvO₂may serve an index in confirming the endpoint of fluid resuscitation for patients with septic shock. Fluid resuscitation therapy under the guidance of LC and ScvO₂is more accurate and reliable than the guidance of ScvO₂alone.

Early predictive value of hemodynamic parameters during fluid resuscitation in patients with sepsis shock

To investigate the short term predictive value of hemodynamic parameters during fluid resuscitation in patients with septic shock. Data of 76 patients with septic shock admitted to Department of Critical Care Medicine of Beijing Shijitan Hospital from January 2013 to October 2014 were retrospectively analyzed. The hemodynamic parameters were monitored by pulse indicator continuous cardiac output ( PiCCO ), including mean arterial pressure ( MAP ), stroke volume index ( SVI ), cardiac index ( CI ), global ejection fraction ( GEF ), global end diastolic volume index ( GEDVI ), intrathoracic blood volume index ( ITBVI ), extravascular lung water index ( EVLWI ), systemic vascular resistance index ( SVRI ), and pulmonary vascular permeability index ( PVPI ). They were recorded before and 6 hours after fluid resuscitation. According to the prognosis on the 7th day, the patients were divided into survival group ( n = 42 ) and death group ( n = 34 ). The PiCCO records between two groups were compared and a receiver operating characteristic ( ROC ) curve for predicting the outcome was plotted to find the cut-off point value for each PiCCO record before and 6 hours after fluid resuscitation.The factors for predicting 7-day prognosis of patients with septic shock were analyzed by multivariate logistic regression analysis. (1) Compared with those before fluid resuscitation, EVLWI and PVPI were significantly decreased at 6 hours after fluid resuscitation in the survival group [ EVLWI ( mL/kg ): 7.33±1.72 vs. 9.07±2.81, PVPI: 1.39±0.34 vs. 1.74±0.50, both P<0.01 ] but they were significantly increased in the death group [ EVLWI ( mL/kg ): 12.62±3.58 vs. 8.97±2.74, PVPI: 2.36±0.81 vs. 1.73±0.60, both P<0.01 ], and MAP in the death group decreased after fluid resuscitation [ MAP ( mmHg, 1 mmHg = 0.133 kPa ): 70.53±12.12 vs. 77.06±13.48, P<0.01 ]. (2)ROC curve showed that the area under ROC curve ( AUC ) of EVLWI at 6 hours after fluid resuscitation was 0.914, cut-off value was 9.50 mL/kg, the sensitivity was 82.4% and the specificity was 88.1%. The AUC of PVPI was 0.890, when cut-off value was 1.75, the sensitivity was 73.5%, and the specificity was 92.9%. (3) It was shown by multivariate logistic regression analysis that only EVLWI at 6 hours after fluid resuscitation was an independent predictor for 7-day prognosis of septic patient [ odds ratio ( OR ) = 0.546, 95% confidence interval ( 95%CI ) = 0.852-0.976, P = 0.006 ]. PiCCO monitoring indicators such as EVLWI, PVPI and MAP have certain prognostic value for septic patients, but only EVLWI at 6 hours after fluid resuscitation is an independent prognostic factor for short term prognosis.

Is palmar surface area a reliable tool to estimate burn surface areas in obese patients?

Estimating TBSA burned is critical to the initial management and fluid resuscitation of patients who have sustained burn injuries. TBSA of scattered burn injuries are frequently estimated using the patient's percentage palmar surface area (%PSA), which is taught as being 1% of the TBSA. This study investigates the relationship of %PSA to TBSA as the body mass index (BMI) increases. Age, sex, race, weight, height, and PSA was collected from obese and nonobese volunteers. TBSA was calculated using the Mosteller, DuBois-DuBois, Livingston and Scott, and Yu formulas. The %PSA relative to TBSA was calculated in obese and nonobese volunteers. Data from 100 subjects were collected. Fifty subjects had a BMI >30 and 50 had a BMI <30. The average age was 41 years (22-77 years old). There were 68 women and 32 men. The %PSA ranged from 0.49% of TBSA with a BMI of 58.7 to 1.15% of TBSA with a BMI of 22.6. This correlation of %PSA to BMI was statistically significant with all of the formulas. We should not assume that the %PSA is always 1% of TBSA, especially in obese patients.

Reliability of lactate clearance rate in evaluating efficacy of early fluid resuscitation in patients with severe sepsis

Objective To evaluate the reliability of lactate clearance rate in evaluating the efficacy of early fluid resuscitation in the patients with severe sepsis.Methods One hundred and forty-two patients with severe sepsis,aged 28-87 yr,were enrolled in the study.Isotonic crystalloid fluid was infused after admission to ICU to maintain central venous pressure ≥ 8 mmHg,mean arterial pressure ≥ 65 mmHg,central venous oxygen saturation (ScvO2) ≥ 70％,and urine output ≥ 0.5 ml·kg 1 ·h-1 within 6 h.The patients were divided into 2 groups according to the treatment outcome:survival group and death group.Immediately before fluid resuscitation and at 6,12 and 24 h after fluid resuscitation,blood samples were collected from the central vein for blood gas analysis and ScvO2 was recorded.Blood samples were collected from the peripheral vein for determination of the concentration of lactate and lactate clearance rate was calculated.Results Compared with survival group,the lactate clearance rate was significantly decreased at 6,12 and 24 h after fluid resuscitation,and no significant change in ScvO2 was found in death group.Conclusion Lactate clearance rate can evaluate the efficacy of early fluid resuscitation in the patients with severe sepsis. Key words: Lactate ; Sepsis ; Fluid therapy

Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation in patients with septic shock

BackgroundInitial fluid resuscitation is an important hemodynamic therapy in patients with septic shock. The Surviving Sepsis Campaign Guidelines recommend fluid resuscitation with volume loading according to central venous pressure (CVP). However, patients with septic shock often develop a transient decrease in cardiac function; thus, it may be inappropriate to use CVP as a reliable marker for fluid management.MethodsWe evaluated 40 adult patients with septic shock secondary to intra-abdominal infection who received active treatment and were monitored using transthoracic echocardiography (TTE) and CVP for 2 days after admission to our intensive care unit (ICU). We measured left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), and the pressure gradient of tricuspid regurgitation (TR∆P). The shock status was treated with volume loading and inotrope/vasopressor administration according to the TTE findings. We assessed left ventricular fractional shortening (LVFS) as an index of left ventricular contractility and TR∆P as an index of right ventricular afterload and then examined the correlation between CVP and LVEDD/LAD/TR∆P.ResultsLVFS decreased to ≤30% in 42.5% and 27.5% of patients with septic shock, and severe left ventricular dysfunction with LVFS ≤20% developed in 12.5% and 15.0% of patients on the first and second ICU days, respectively, despite the use of inotropes/vasopressors. Mild pulmonary hypertension as indicated by TR∆P ≥30 mmHg was present in 27.5% and 30.0% of patients on their first and second ICU days, respectively. There was no significant correlation between CVP and LVEDD/LAD/TR∆P. The hospital mortality rate in this study was 10.0%, although the predicted mortality based on the Acute Physiology and Chronic Health Evaluation II score was 58.7%.ConclusionsOur results suggest that CVP is not a reliable marker of left ventricular preload for fluid management during the initial phase of septic shock. Assessment of left ventricular preload, right ventricular overload, and left ventricular contractility using TTE seems to be more informative than the measurement of CVP for fluid resuscitation since some patients developed left ventricular dysfunction and/or right ventricular overload.

A necessary evil? Intra-abdominal hypertension complicating burn patient resuscitation.

ObjectiveSevere burns are devastating injuries that result in considerable systemic inflammation and often require resuscitation with large volumes of fluid. The result of massive resuscitation is often raised intra-abdominal pressures leading to Intra-abdominal hypertension (IAH) and the secondary abdominal compartment syndrome. The objective of this study is to conduct (1) a 10 year retrospective study to investigate epidemiological factors contributing to burn injuries in Alberta, (2) to characterize fluid management and incidence of IAH and ACS and (3) to review fluid resuscitation with a goal to identify optimal strategies for fluid resuscitation.DesignA comprehensive 10-year retrospective review of burn injuries from 1999.Outcome MeasuresAge, sex, date, mechanism of injury, location of incident, on scene vitals and GCS, type of transport to hospital and routing, ISS, presenting vitals and GCS, diagnoses, procedures, complications, hospital LOS, ICU LOS, and events surrounding the injury.ResultsOne hundred and seventy five patients (79.4% M, 20.6% F) were identified as having traumatic burn injuries with a mean ISS score of 21.8 (±8.3). The mean age was 41.6 (±17.5) (range 14-94) years. Nearly half (49.7%) of patients suffered their injuries at home, 17.7% were related to industrial incidents and 14.3% were MVC related. One hundred and ten patients required ICU admission. ICU LOS 18.5 (±8.8) days. Hospital LOS 38.0 (±37.8) days. The mean extent of burn injury was 31.4 (±20.9) % TBSA. Nearly half of the patients suffered inhalational injuries (mild 12.5%, moderate 13.7%, severe 9.1%). Thirty-nine (22.2%) of patients died from their injuries. Routine IAP monitoring began in September, 2005 with 15 of 28 patients having at least two IAP measurements. The mean IAP was 16.5 (±5.7) cm H2O (range: 1-40) with an average of 58 (±97) IAP measurements per patient. Those patients with IAP monitoring had an average TBSA of 35.0 (±16.0)%, ISS of 47.5 (±7.5). The mean 48 hr fluid balance was 25.6 (±11.1)L exceeding predicted Parkland formula estimates by 86 (±32)%.ConclusionsFurther evaluation of IAP monitoring is needed to further characterize IAP and fluid resuscitation in patients with burn injuries.

Individual patient data meta-analysis of hydroxyethyl starch 130/0.4–0.42 versus crystalloid for fluid resuscitation in patients with severe sepsis: a statistical analysis plan

Individual patient data meta-analysis of hydroxyethyl starch 130/0.4–0.42 versus crystalloid for fluid resuscitation in patients with severe sepsis: a statistical analysis plan

Impact of fluid management during the three ICU days after admission in patients with ARDS

The optimal evaluation of fluid resuscitation in patients with acute respiratory distress syndrome (ARDS) remains to be clearly elucidated. The purpose of this study was to clarify the influence of fluid overload in patients with ARDS.

The value of stroke volume variation in prediction of responsiveness to fluid resuscitation in patients with septic shock

Objective To determine whether stroke volume variation (SVV) in relation to volume loading in mechanically ventilated patients with septic shock.Methods Data of thirty-two mechanically ventilated patients with septic shock admitted from Dec 2009 to May 2012 were prospectively analyzed.Cardiac index (CI),stroke volume (SV),systemic vascular resistance index (SVRI) and stroke volume variation (SVV) were measured by FloTrac/Vigileo before and after fluid resuscitation (250 mL saline in 10 min).Patients with an increase in SV (△SV) ≥ 10％ and ＜ 10％ after fluid volume loading were classified as responders and non-responders,respectively.The comparisons between these two sorts of patients were assessed by using two sample Student' s t-test,and comparisons between changes before and after fluid challenge were assessed by using a paired Student' s t-test.A Pearson' s correlation analysis was employed for evaluate the correlation between △SV and other haemodynamic variables.The roles of SVV,central venous pressure (CVP),mean artery pressure (MAP) and the changes of CVP (△CVP),MAP (△MAP) after fluid administration in predicting volume responsiveness were evaluated by receiver operating characteristic (ROC) curve.Results Thirty-two patients with septic shock were included in this study.There were 54 instances of fluid challenge performed,among which 35 instances were defined as response group.Significantly increased SV induced by fluid challenge was assigned into response group (83.6 ± 15.6) mL vs.(68.5 ± 14.2) mL,P ＜0.01,while in non-response group,there were no significant change in SV (P ＞0.05).SVV was significantly correlated with SV before fluid loading (r =0.522,P ＜ 0.01).The area under the ROC curve (AUC) for stroke volume variation (SVV) was 0.898 (95％ CI:0.796-1.000).Using SVV ≥ 11.5％ as the threshold to predict fluid responsiveness,the sensitivity was 94％ and specificity was 84％.Conclusions SVV can be used to predict fluid responsiveness in patients with septic shock. Key words: Septic shock; Stroke volume variation; Volume responseness; Fluid challenge

The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: Things to keep in mind

IntroductionAccurate estimation of burn size is of critical importance, as it is incorporated in every resuscitation formula. The aim of this study was to investigate total burn surface area (TBSA) accuracy among burn specialists, evaluate the potential impact of incorrect evaluation on variations of resultant fluid resuscitation volumes and to discuss future possibilities to estimate or measure TBSA more precisely. MethodsIn a poll during two international burn meetings in 2010 and 2011 demonstrating three pictures of patients with different burn wound patterns and sizes we asked participants to estimate the total surface area burned in percentages. We then calculated resultant fluid volume differences based on established resuscitation formulas. ResultsIn the polled 80 participants, the estimations for three patients demonstrated the following differences (DIF=MAX−MIN): for patient 1, 2 and 3 they were 22.5 (25–2.5), 16.5 (20–3.5) and 31.5 (40–8.5) %TBSA, respectively. Based on these differences we calculated the volume differences for patients 1,2 and 3, which were 1080ml (Cincinnati Formula), 5280ml (Parkland Formula) and 2016ml (Cincinnati Formula), respectively. ConclusionsThe analysis showed high deviations of total body surface area among participants, also resulting in large variations of initial fluid resuscitation volumes. One option to address estimation variances is to perform more accurate assessments; also incorporating new technologies aiding to improve the quality of body surface estimations and related decisions.

VOLUME THERAPY IN ACUTE PANCREATITIS

Fundamental management is required soon after a diagnosis of acute pancreatitis has been made and includes monitoring of the conscious state, the respiratory and cardiovascular system, the urinary output, adequate fluid replacement and pain control, blood purification therapy and nutritional support. An adequate dose of fluid replacement is essential to stabilize cardiovascular dynamics and the dose should be adjusted while assessing circulatory dynamics constantly. Current clinical practice guidelines recommend aggressive fluid resuscitation despite limited prospective data. Fluid therapy remains the mainstay of early management of patients with acute pancreatitis and severe acute pancreatitis. High-level evidence is lacking to guide protocols for fluid resuscitation in patients presenting with acute pancreatitis. In those patients with severe acute pancreatitis, the available evidence indicates that controlled fluid resuscitation with crystalloids and colloids offers the best outcome. Hematocrit remains a useful marker to guide fluid resuscitation in acute pancreatitis. However, the timing and ideal “cut-off” level needs to be determined. Acta Medica Medianae 2013;52(3):55-60.

Albumin for fluid resuscitation in patients with sepsis: what do we expect for?

Albumin for fluid resuscitation in patients with sepsis: what do we expect for?

Colloid Solutions for Fluid Resuscitation in Patients with Sepsis: Systematic Review of Randomized Controlled Trials

BackgroundColloids are widely used for fluid resuscitation in patients with sepsis. But the optimal type of fluid remains unclear. ObjectiveOur aim was to assess the effects on mortality and safety of different colloid solutions in patients with sepsis requiring volume replacement by examining direct comparisons of colloid solutions. MethodsWe searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, China Biological Medicine Database, VIP Chinese Journals Database, and CNKI China National Knowledge Infrastructure Whole Article Database. Randomized clinical trials comparing different colloids in septic patients needing fluid resuscitation were selected. ResultsSeventeen randomized clinical trials with a total 1281 participants met the inclusion criteria. Mortality was obtained in all trials. For intervention of albumin vs. hydroxyethyl starch solution (HES), the relative risk (RR) of death was 0.98 (95% confidence interval [CI] 0.74−1.30). For intervention of albumin vs. gelatin, the RR of death was 2.4 (95% CI 0.31−18.35). For intervention of gelatin vs. HES, the RR of death was 1.02 (95% CI 0.79−1.32). For the intervention of HES vs. dextran, the RR of death was 1.38 (95% CI 0.28−6.78). For the intervention of gelatin vs. dextran, RR of death was not estimable. For albumin vs. dextran, no trial was included. Four trials of intervention of albumin vs. HES recorded the change of severity score. ConclusionsThere is no evidence that one colloid solution is more effective and safer than another for fluid resuscitation in sepsis. The severity score is improved in HES, but the confidence intervals are wide.

Effect of 6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride (Voluven®) on complications after subarachnoid hemorrhage: a retrospective analysis

Background6% Hydroxyethyl Starch 130/0.4 in 0.9% Sodium Chloride (Voluven®; 6% HES 130/0.4) is a colloid often used for fluid resuscitation in patients with subarachnoid hemorrhage (SAH), despite a lack of safety data for this use. The purpose of our study was to evaluate the effect of 6% HES 130/0.4 on major complications associated with SAH.MethodsMedical records of all patients presenting between May 2010 and September 2012 with aneurysmal SAH were analyzed. Patients were divided in two groups based on the administration of 6% HES 130/0.4; HES group (n=57) and Non-HES group (n=72). The primary outcome included a composite of three major complications associated with SAH: Delayed Cerebral Ischemia (DCI), Hydrocephalus (HCP) requiring cerebrospinal fluid (CSF) shunting, and Rebleeding.ResultsThe study groups were similar with respect to most characteristics except the incidences of hypertension, ischemic heart disease, Fisher grade and lowest hemoglobin during stay. The odds of developing the primary composite outcome was higher in the HES group [OR= 3.1(1.30-7.36), p=0.01]. The patients in the HES group had a significantly longer median duration of hospital (19 vs 14 days) and Neurointensive Care Unit stay (14 vs 10 days) compared to the Non HES group.ConclusionWe observed increased complications after SAH with 6% HES 130/0.4 (Voluven®) administration. An adequately powered prospective randomized controlled trial into the safety of 6% HES 130/0.4 in this patient population is warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/2193-1801-2-314) contains supplementary material, which is available to authorized users.

Nuevas recomendaciones sobre la utilización de soluciones de albúmina humana en pacientes con sepsis grave y shock séptico. Una evaluación crítica de la literatura

The third edition of the Surviving Sepsis Campaign guidelines opens the door to the use of albumin for fluid resuscitation in patients with severe sepsis and septic shock. This recommendation is based on a recent meta-analysis that included studies with evidence of insufficient plasma expansion in the control group and studies performed in children with malaria with clear statistical heterogeneity (P for interaction=.02). After excluding pediatric studies, the confidence interval of the effect estimate was consistent with a mortality excess in the group treated with albumin (OR=.87 [95%CI: .71 to 1.07]). Two new randomized studies reported after publication of the meta-analysis found no benefit in patients treated with albumin. Given the uncertainty about the true effect of albumin (due to the existence of indirectness and imprecision) and its cost considerations, it is suggested not to use albumin in the initial resuscitation of patients with severe sepsis and septic shock (GRADE2C).

Fluid Resuscitation in Patients with Severe Sepsis or Septic Shock: Which Fluid Should be Administered?

Fluid Resuscitation in Patients with Severe Sepsis or Septic Shock: Which Fluid Should be Administered?

Diagnosis and treatment of infectious shock after percutaneous nephrostolithotomy or ureteroscopic lithotripsy

Objective To summarize experience about the infectious shock after percutaneous nephrostolithotripsy (PCNL) or ureteroscopic lithotripsy.Methods We retrospectively analyzed the clinical data of 6 patients who occurred infectious shock after oinimally invasive percutaneous nepholithotomy (mini-PCNL) during January 2011 to June 2012.The 6 patients were diagnosed as infectious shock,and were given anti shock,anti infection treatment.Results All 6 patients were discontinued gradually the pressor agent within 3-5 days and conditions were stable,after 5-10 days of temperature and blood returned to normal.Conclusion Early fluid resuscitation in patients with septic shock to improve tissue perfusion and oxygen supply is of important value,postoperative septic shock patients are recommended for early application of broad-spectrum antibiotics with curative effect such as imipenem and meropeuem. Key words: Percutaneous nephrolithotripsy (PCNL); Ureteroscopic lithotomy; Infectious shock

A comparative analysis of nasogastric and intravenous fluid resuscitation in patients with malignant obstructive jaundice prior to endoscopic biliary drainage

Background:An alternative to intravenous is nasogastric fluid administration through normal functioning gut. Though not common, this practice has significance in mass causalities and elective situations.Aim:The study was designed to compare nasogastric and intravenous fluid resuscitation in malignant obstructive jaundice (OJ) and their effect on endotoxemia.Materials and Methods:Sixty patients with malignant OJ undergoing endoscopic biliary drainage were randomized into two groups. A total of 4 l of fluid (Ringer's lactate) was administered to Group A through nasogastric tube and to Group B through intravenous route for 48 h. Vital parameters, serum bilirubin, serum creatinine, creatinine clearance rate, electrolytes, and endotoxemia were monitored.Results:Significant improvement in blood pressure (Group A, P = 0.014; Group B, P = 0.020) and significant decrease in serum bilirubin level (Group A, P = 0.001; Group B, P > 0.0001) was observed in both groups after resuscitation. Significantly decreased (P = 0.036) post hydration endotoxin level was observed in Group A as compared to Group B. Febrile events were significantly higher (P = 0.023) in Group B as compared to Group A (6 vs 0). Electrolyte abnormalities were found more in Group B, however statistically insignificant.Conclusion:In OJ patient undergoing biliary drainage, preoperative fluid resuscitation through nasogastric tube may be helpful in reducing postoperative septic complications and endotoxemia.

Simple method of fluid resuscitation in patients requiring emergency thoracotomy through direct cardiac cannulation

Patients who are critically injured with imminent cardiac arrest may require immediate thoracotomy as an integral component of their initial resuscitation in the emergency department. Fluid resuscitation can be difficult owing to a shutdown state. A simple method for fluid delivery in patients requiring emergency department clamshell thoracotomy entails the insertion of a large bore venous catheter directly into the right atrium at its appendage and using it for fluid resuscitation (Fig 1). This method is quick, safe and easily reproducible. Once the patient is stable, the catheter can be removed and a simple purse string suture used to close the atrium. Figure 1 Clamshell thoracotomy with a large bore venous catheter in the right atrium (arrow)