Resuscitation Regimens Research Articles

Clinical and Epidemiological Profile of Deep Second Degree Burn Patients Treated with Platelet Lysate

The wound healing process in burn victims is still a problem today despite the advances made in the management of these patients with the different resuscitation regimens, the advent of antibiotic therapy as well as the different local treatments used. The local application of a high concentration of growth factor through the use of halogenic platelet concentrates lyzed by freezing- thawing has been done in the past with the aim of accelerating the healing process of the various wounds. The aim of this work is to describe Clinical and epidemiological profile of deep second degree burn patients treated with platelet lysate. A longitudinal and prospective study was carried out in 30 adult patients with deep second-degree burns with boiling water with a burned body surface area ≤ 5%, treated locally with allogeneic platelet lysate in the Burn centre and Plastic Surgery Service of the General Hospital “Dr. Juan Bruno Zayas Alfonso” in Santiago de Cuba, during the period of February 2015 to February 2016.A total of 30 adult patients have been studied. The mean age was 33.93. Female sex predominated with a male/female ratio of 1/2. The most frequent location of burns was in the lower limbs accounting for 36.6% of patients, followed by the upper limbs and anterior trunk at 26.7% in both cases. For the study group, the epitelization time was less than 21 days and in the majority of cases (66.7%) this time was 7-13 days. Non-relevant side effects were observed in 80% of patients and included pruritus (50%), perilesional erythema (8.3%) and pain in 29.2% of patients. Apart from these side effects, no complications have been observed in our patients. The promising results reported in this study and in the literature warn that platelet lysate may become a potential therapeutic candidate for deep second- degree burns from boiling water.

BRAIN RESUSCITATION IN SEVERE HEAD INJURY AT SANGLAH CENTRAL GENERAL HOSPITAL DENPASAR 2020

ABSTRACT
 
 Head injury is a serious problem worldwide and causes morbidity and mortality at a young age. The increase in the number of severe head injuries continues to occur along with the number of accidents. This study aimed to examine the characteristics of brain resuscitation in patients with a severe head injury. Descriptive research with cross-sectional research method and the data obtained as many as 35. Data processing using SPSS and displayed in a distribution table according to the variables. This study found that patients with severe head injuries were most often at the age of >45 years, namely 18 people (51.4%), and male sex was more common than women as many as 24 people (68.6%). The most common GCS was found with GCS 3-5 as many as 21 people (60%). The brain resuscitation regimen in patients with a severe head injury was given crystalloid solution (0.9% NaCl, Ringer's lactate) in 35 people (100%), mannitol 20% in 22 people (62.9%), and phenytoin in 33 people (94.3%). The GOS value of all patients with severe head injury with a GOS value of 1 or died (100%). Most deaths from severe head injury patients were in the first <48 hours as many as 27 people (77.1%)
 Keywords : brain resuscitation, traumatic brain injury, severe head injury.

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial

BackgroundFluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.MethodsA pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan–Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built.ResultsA total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications.ConclusionAmong postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.

The Role of Ultrasound Guided IVC-CI versus Central Venous Pressure in Assessment of Critically Ill Patients

Abstract Background: Both hypovolemia and volume over load increase the morbidity and mortality of patients. So evaluation of intravascular volume status is the first important step in patients with signs of shock. Use of non invasive method as Inferior Vena Cava (IVC) measurements is one of methods to avoid complications of invasive procedure as central venous pressure monitoring. Aim of Study: This study aimed to provide a useful guide for noninvasive intravascular volume status (as diagnosed and manage) and to evaluating the correlation between Inferior Vena Cava-Collapsibility Index (IVC-CI) measured with ultrasonography versus central venous pressure. Patients and Methods: This study was a prospective observation study that was conducted on forty critically ill patients of both sexes, aging >!21 years old of ASA (III & IV) with signs of shock, admitted in the ICU at Al-Zahraa Uni-versity Hospitals during the last two year (October 2018 till October 2020), were enrolled in the non probability consecutive sampling after approval of the Al-Azhar University Ethical Committee and written informed consent from the patient or the 1st degree relatives in case of comatosed patient. After were screened for signs of shock, hemodynamic parameters were monitored continuously then 500ml of Nacl 0.9% was administered in 15 minutes and clinical response was observed with measures taken by using ultrasound. Then the patients were divided into responder and non responder. Results: In our study there was 24 patients of 40 patients (60%) responded to volume resuscitation. While 16 patients of 40 patients (40%) did not respond to volume resuscitation regimen and then blood pressure improved only after intro-duction of vasopressor as regarding to demographic data, there was no significant difference between two groups, as regarding to heart rate, MAP, and central venous pressure was no significant difference between two groups. In responder group there was strongly correlated that was highly significant of CVP and IVC-CI, in non responder group, there was no correlation between CVP and IVP-CI throughout the study. Conclusion: Inferior vena cava collapsibility index as-sessment is relatively safe option and sensitive at least when compared to measuring CVP.

Efficacy of resuscitative infusion with hemoglobin vesicles in rabbits with massive obstetric hemorrhage

Hemoglobin vesicles have been developed as artificial oxygen carriers, and they have the potential to serve as a substitute for red blood cell transfusion. This study aimed to evaluate the efficacy of hemoglobin vesicle infusion for the initial treatment instead of red blood cell transfusion in rabbits with massive obstetric hemorrhage. Pregnant New Zealand white rabbits (28th day of pregnancy; normal gestation period, 29-35 days) underwent uncontrolled hemorrhage to induce shock by transecting the right midartery and concomitant vein in the myometrium. Subsequently, rabbits received isovolemic fluid resuscitation through the femoral vein with an equivalent volume of hemorrhage every 5 minutes. Resuscitative infusion regimens included 5% human serum albumin (n=6), stored washed red blood cells with plasma (vol/vol=1:1; n=5), and hemoglobin vesicle with 5% human serum albumin (vol/vol=4:1; n=5). A total of 60 minutes after the start of bleeding, rabbits underwent surgical hemostasis by ligation of the bleeding vessels and then were monitored for survival within 24 hours. During fluid resuscitation, hemoglobin vesicle infusion and red blood cell transfusion maintained a mean arterial pressure of >50 mm Hg and a hemoglobin concentration of >9 g/dL and prevented the elevation of plasma lactate. In contrast, resuscitation with 5% human serum albumin alone could not prevent hemorrhagic shock as evidenced by a low mean arterial pressure (40 mm Hg), a low hemoglobin concentration (2 g/dL), and a marked elevation of plasma lactate. All animals in the red blood cell group and the hemoglobin vesicle group survived more than 8 hours, whereas all animals in the 5% human serum albumin group died within 8 hours. Hemoglobin vesicle infusion may be effective in the initial management of massive obstetric hemorrhage.

Abstract 118: Resuscitative Transfusion With Hemoglobin Vesicles in the Management of Post-Partum Hemorrhage

Background: We developed a Hemoglobin vesicles (HbV), which are artificial substitute for Red blood cells (RBCs). Objective: To evaluate the efficacy of HbV for alternative treatment instead of RBCs transfusion in rabbits with hemorrhagic shock due to post-partum hemorrhage. Methods: New Zealand white rabbits at late gestation underwent uncontrolled hemorrhagic shock by transecting a right mid-artery in the myometrium, after cesarean section of right side uterus. Initially, in the simulated ordinal treatment of bleeding, rabbits received colloid fluids (Voluven®) through an femoral vein with equivalent volume of the bleeding every 5 minutes. Once blood loss achieved 100ml, animals subsequently faced on critical hemorrhagic situation, where mean arterial pressure (MAP) reduced to approximately 48mmHg. They were randomly divided into three isovolemic resuscitation regimens: continuing colloid fluid resuscitation (n=4); transfusion of autologous washed RBCs with plasma (n=4); HbV infusion combining 5% human serum albumin (n=4). After 60 minutes of bleeding, all animals underwent surgical control of bleeding and cesarean section of left side uterus. Results: At the point of critical hemorrhagic situation, Hb concentration reduced to 4.8 g/dl. At the end of resuscitation, HbV infusion regained MAP and restored Hb concentration as well as RBCs transfusion, besides colloid fluid resuscitation exaggerated the severe hemorrhagic shock as shown in the table. Conclusions: HbV treatment may be effective in the management of post-partum hemorrhagic shock.

2964 Real World Evidence Demonstrates a Difference in the Presenting Characteristics of Cirrhotic Patients Who Received Albumin Compared to Those Who Received Only Crystalloids

INTRODUCTION: Cirrhosis affects over 633,000 adults in the US with recent mortality rates increasing by 3.4% annually. Readmission rates have also been shown to be high. These patients may be resuscitated with albumin, crystalloids, or both. METHODS: This study used real-world data to examine differences in the burden of disease among adults admitted with cirrhosis who were treated with albumin (&lt;24 hours (early) versus &gt;24 hours (late) after admission) versus crystalloids alone, between January 1, 2009, and December 31, 2016. We used a nationwide Electronic Health Record database (Cerner Health Facts®) and compared Model for End-stage Liver Disease Sodium (MELD-Na) score and Elixhauser Comorbidity Index across the fluid resuscitation groups. RESULTS: We identified 86,432 patients admitted with cirrhosis. The mean age was 59.2 years and the majority (55.4%) were male. Patients who received albumin (n = 26,835) had higher MELD-Na scores at presentation (mean score 22.0 in patients treated early and mean score 19.5 in patients treated late), versus patients who received only crystalloids (n = 59,597; mean score 14.1). Additionally, at presentation, patients who received albumin had a higher Elixhauser Comorbidity Index (mean 18.8 and 19.9 in patients receiving albumin early versus late respectively) versus patients who received crystalloids alone (mean 16.3). CONCLUSION: Cirrhotic patients who were treated with albumin had, at presentation, a higher MELD-Na score and Elixhauser Index, which represents a greater burden of disease compared to patients treated with only crystalloids. Further research is needed to examine differences in clinical and economic outcomes, including complications of cirrhosis such as acute kidney injury, spontaneous bacterial peritonitis, ascites, and procedures of large volume paracentesis, following different fluid resuscitation regimens.

The Israel Defense Forces experience with freeze-dried plasma for the resuscitation of traumatized pediatric patients.

With the growing recognition of the disadvantages of crystalloid- and colloid-based resuscitation and the advantages of using blood products as the preferred resuscitation fluid, the Israel Defense Forces Medical Corps (IDF-MC) adopted plasma as the primary volume resuscitation regimen in 2013. While data are accumulating for prehospital plasma transfusion, little to no data exist regarding using plasma as a prehospital resuscitation fluid for traumatized pediatric patients. All patients treated by the IDF-MC personnel are recorded in the IDF Trauma Registry, a unique prehospital trauma registry. All patients treated by the IDF advanced life support providers with FDP at the point of injury between April 2013 and June 2018 who were younger than 18 years at the time of injury were included. Six hundred seventy-nine children were treated by IDF medical providers, of whom 33 (5%) were identified in the IDF Trauma Registry as having received FDP at the point of injury. Most patients (80%) were treated for penetrating injuries. Most patients received one plasma unit. Fifty-four percent of the patients were also treated by Tranexamic Acid (TXA) and 48% were transfused with crystalloids. In 33% of patients, additional life-saving interventions were performed. While the ideal resuscitation fluid for the pediatric population remains to be determined, it seems reasonable to pursue a similar approach to that of applied that for adults. In the IDF-MC, the resuscitation fluid of choice for trauma patients in hemorrhagic shock is freeze-dried plasma transfused at the point of injury. The current study demonstrates the feasibility of FDP administration in the prehospital scenario for injured children and further supports the growing confidence in the use of FDP for the treatment of pediatric trauma patients. Retrospective descriptive study, level IV.

Restricted fluid resuscitation in suspected sepsis associated hypotension (REFRESH): a pilot randomised controlled trial.

To determine if a regimen of restricted fluids and early vasopressor compared to usual care is feasible for initial resuscitation of hypotension due to suspected sepsis. A prospective, randomised, open-label, clinical trial of a restricted fluid resuscitation regimen in the first 6h among patients in the emergency department (ED) with suspected sepsis and a systolic blood pressure under 100mmHg, after minimum 1000ml of IV fluid. Primary outcome was total fluid administered within 6h post randomisation. There were 99 participants (50 restricted volume and 49 usual care) in the intention-to-treat analysis. Median volume from presentation to 6h in the restricted volume group was 2387ml [first to third quartile (Q1-Q3) 1750-2750ml]; 30ml/kg (Q1-Q3 32-39ml/kg) vs. 3000ml (Q1-Q3 2250-3900ml); 43ml/kg (Q1-Q3 35-50ml/kg) in the usual care group (p < 0.001). Median duration of vasopressor support was 21h (Q1-Q3 9-42h) vs. 33h (Q1-Q3 15-50h), (p = 0.13) in the restricted volume and usual care groups, respectively. At 90-days, 4 of 48 (8%) in the restricted volume group and 3 of 47 (6%) in the usual care group had died. Protocol deviations occurred in 6/50 (12%) in restricted group and 11/49 (22%) in the usual care group, and serious adverse events in fourcases (8%) in each group. A regimen of restricted fluids and early vasopressor in ED patients with suspected sepsis and hypotension appears feasible. Illness severity was moderate and mortality rates low. A future trial is necessary with recruitment of high-risk patients to determine effects on clinical outcomes in this setting.

Resuscitative therapy with erythropoietin reduces oxidative stress and inflammatory responses of vital organs in a rat severe fixed-volume hemorrhagic shock model

Hemorrhagic shock (HS) still has a high mortality rate and none of the known resuscitative regimens completely reverse its adverse outcomes. This study investigated the effects of different models of resuscitative therapy on the healing of organ damage in a HS model. Male Wistar rats were randomized into six groups: Sham, without HS induction; HS, without resuscitation; HS+Blood, resuscitation with the shed blood; HS+Blood+NS, resuscitation with blood and normal saline; HS+Blood+RL, resuscitation with blood and Ringer's lactate; EPO, erythropoietin was added to the blood and RL. Blood and urine samples were obtained 3 h after resuscitation. Kidney, liver and brain tissue samples were harvested for multiple organ failure evaluation. Survival rate was the highest in the Sham, EPO and HS+Blood+RL groups compared to others. Plasma creatinine concentration, ALT, AST, urinary NAG activity and renal NGAL mRNA expression significantly increased in the HS+Blood+RL group compared to the Sham group. There was a significant increase in tissue oxidative stress markers and pro-inflammatory cytokines in HS+Blood+RL group compared to the Sham rats. EPO had more protective effects on multiple organ failure compared to the HS+Blood+RL group. EPO, as a resuscitative treatment, attenuated HS-induced organ damage. It seems that it has a potential to be attractive for clinical trials.

Traumatic coagulopathy and massive transfusion: improving outcomes and saving blood

IntroductionDysfunction of the coagulation system, termed trauma-induced coagulopathy (TIC), is a major problem in patients who bleed after injury. Trauma haemorrhage is considered one of the leading preventable causes of death worldwide. Deaths occur early and, despite the presence of trauma teams and large transfusions of blood products, outcomes remain poor.MethodsWe conducted a multimodal programme of work to develop our understanding of coagulopathy and its optimal management. We studied the epidemiology, management and health economics of trauma haemorrhage, including the provision of care during mass casualty events. We combined systematic reviews of the literature with a national study of trauma haemorrhage, its transfusion management and associated health-care costs. We further examined several point-of-care coagulation tools for their ability to diagnose coagulopathy and assess the response to blood component therapy. We progressively implemented our findings into practice and assessed the outcomes of trauma patients presenting to our major trauma centre. To examine different approaches to the provision of blood to casualties in a mass casualty event, we constructed a discrete event model based on data from the 2005 London bombings.Key resultsOur systematic reviews found little strong evidence for the existing diagnostic tools or the practice of delivery of blood components in trauma haemorrhage. Our national study recruited 442 patients in 22 hospitals and found that the 1-year mortality rate for massive haemorrhage approached 50%. Half of these deaths occurred in the first 24 hours after injury and half of these occurred in the first 4 hours. We identified this early time window as a period when the provision of blood component therapy was often below the recommended thresholds and blood component therapy was delivered inconsistently. Studying early TIC we determined that loss of fibrinogen and excessive fibrinolysis were key derangements. We were able to determine that rotational thromboelastometry could identify early coagulopathy within 5 minutes, a large improvement on laboratory tests. We were further able to show how existing damage control resuscitation regimens with high-dose plasma do not maintain haemostatic competency during haemorrhage. In total, the estimated cost of treating a major haemorrhage patient was £20,600 and the estimated cost of treating a massive haemorrhage patient was £24,000. Nationally, the estimated cost of trauma haemorrhage is £85M annually. In mass casualty situations, early results show that the only mutable factor that affects the provision of care to a large degree, in the initial phase of the response, is the level of blood stocks held in the receiving hospital.ConclusionsThis multimodal programme of work has led to new understandings of the epidemiology of trauma haemorrhage and its underlying mechanisms and clinical course. We have defined diagnostic tools and trigger thresholds for identification and management and increased our understanding of how blood component and other therapeutics affect coagulopathy and when they are likely to be most effective. This diagnostic work has been taken forward at an international level to produce new personalised guidelines for the management of trauma haemorrhage. The findings have had important therapeutic implications, which have led to important changes in practice that have been incorporated into new national and international guidelines.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

The problem of burns

Background: Burns due to accidents are a common cause of morbidity and mortality in the Indian sub-continent. The causes being preventive, warrant a better understanding of the epidemiology to know the seriousness of the situation, implement better medical care and prevent such accidents. Aim was to study the morbidity and mortality related to percentage of burns.Methods: This is a retrospective observational study where patients admitted with burns 2013 and 2015 were evaluated. Data with respect to sex, age, percentage of burns, air-way burns, mode and cause of burns, cause of death and length of hospitalization were analyzed.Results: 65.3% of the patients were females and 34.7% males, with a male: female ratio of 0.53:1. A total mortality of 43.71% was seen. Maximum patients belonged to age group 21-40 years which also constituted 28.74% (highest) of the above total mortality. More than 50 % mortality was seen in patients with more than 41% burns. Air way burns were present in 41.31% of the cases; of which 85.51% of cases did not survive. Death due to hypovolemic shock (42.47%) was the main cause of death in the initial 4 days of admission; whereas septicemic shock (57.53%) from the 5th day onward.Conclusions: Morbidity and mortality due to burns is still very high in India, especially in young adults of age groups 21- 40 years. A higher case load for females as seen, being nearly double in in relation to males. Better fluid resuscitation regimens with adequate control of infection is the need of the hour to bring down the mortality. Female sex and more than 41% burns predicts higher mortality. Involvement of the respiratory tract, also predicts higher mortality and may be taken as a reliable indicator of the severity of burns. In the present scenario, we should stress more over the prevention of burns, to easily make available affordable and cheap medical care for the patients and to minimize post burn disability as much as possible.

Effects of resuscitation by different formulation on oxygen metabolism during shock stage of burn injury in swine

To explore the effects of different fluid resuscitation regimens on oxygen metabolism during shock stage of burn injury in swine. Twelve Bama miniature swines were divided into crystal and colloid group (Group 1) and Parkland group (Group 2) according to the random number table. The swine models of burns shock were established. The fluid resuscitation was begun at post injury hour (PIH) 2 according to Chinese formulation or Parkland's formulation, respectively. The blood pressure, urine volume, heart rate, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP) were recorded. The liquid volume was calculated at the first and second PIH 24. The changes in oxygen delivery (DO2), oxygen consumption (VO2), oxygen extraction (O2Ext) and D-lactate (D-LA) were determined before injury and at PIH 4, 8, 24, and 48. Statistical analyses were performed. There were no statistical differences between the two groups in blood pressure, urine volume, heart rate, CVP, PCWP in every interval (all P>0.05). The resuscitation liquid volume in the two groups during the first and second PIH 24 conformed to the domestic consensus. The VO2 at PIH 8 was significantly higher than that of pre-burn in both groups [(190±29) vs (83±42) L·min(-1)·m(-2,) (149±33) vs (85±15) L·min(-1)·m(-2,) both P<0.05], and the VO2 at PIH 8 was significantly higher in Group 1 than that in Group 2 (P<0.05). The DO2 at PIH 24 in Group 1 was significantly lower than that in Group 2 [(686±72) vs (853±81) L·min(-1)·m(-2,) P<0.05]. There were no significant differences between the two groups in O2Ext at any time points (all P>0.05). The D-LA at PIH 8 was significantly higher in Group 1 than that in Group 2 [(53±4) vs (45±6) mmol/L, P<0.05]. There are no significant differences in the resuscitation effects of the crystal and colloid resuscitation regimen and Parkland's formulation on oxygen metabolism during shock stage of burn injury in swine.

The role of pharmacological steroid therapy in preservation of renal function in severely injured patients requiring massive transfusion.

Glucocorticoids (GC) attenuate the post-insult inflammatory response and have been observed to confer end-organ protection following a variety of ischemic insults. We aim to assess this benefit on renal perfusion and function in injured patients requiring massive transfusion. The effect of pharmacologic methylprednisolone (MP) therapy was studied in 118 patients (pts), of whom 60, by random, received 1g MP intraoperatively and 15mg/kg for an additional 3days. Postoperative measurements were made of effective renal plasma flow (ERPF), glomerular filtration by inulin (CIn), creatinine clearance (CCr) and clearances of osmoles (CCosm), sodium (CNa), and free water ([Formula: see text]). Continuous variables were compared between the two groups using the student's t test. Enrolled pts on average received 13.5 units of PRBCs with no differences in the resuscitation regimen. There were no statistically significant differences in the postoperative renal function as measured by ERPF (p=0.57), CIn (p=0.84), CCr (p=0.99), CNa (p=0.07), COsm (p=0.95), and [Formula: see text] (p=0.33). The incidence of renal compromise, as determined by an inulin clearance of <25mL/min or serum creatinine greater than 3.0mg/dL, was also similar. Three patients in the MP treatment group had renal compromise compared to one in the control group. In the absence of larger studies, this study demonstrates that GC likely have no role in preserving renal function in severely injured patients.

Blood Flow Versus Hematocrit in Optimization of Oxygen Transfer to Tissue During Fluid Resuscitation

The effectiveness of fluid resuscitation regimens in hemorrhagic trauma is assessed based on its ability to increase oxygen concentration in tissue. Fluid resuscitation using both crystalloids and colloids fluids, creates a dilemma due to its opposing effects on oxygen transfer. It increases blood flow thereby augmenting oxygen transport but it also dilutes the blood simultaneously and reduces oxygen concentration thereby reducing oxygen transport. In this work we have studied these two opposing effects of fluid therapy on oxygen delivery to tissue. A mathematical model of oxygen diffusion from capillaries to tissue and its distribution in tissue was developed and integrated into a previously developed hemodynamic model. The capillary-tissue model was based on the Krogh structure. Compared to other models, fewer simplifying assumptions were made leading to different boundary conditions and less constraints, especially regarding capillary oxygen content at its venous end. Results showed that oxygen content in blood is the dominant factor in oxygen transport to tissue and its effect is greater than the effect of flow. The integration of the capillary/tissue model with the hemodynamic model that links administered fluids with flow and blood dilution indicated that fluid resuscitation may reduce oxygen transport to tissue.

Effects on vascular permeability with different fluid resuscitation regimens during burn stage in swines

To explore the effects of different fluid resuscitation regimens on vascular permeability during burn stage in swines. A total of 24 Guangxi-BAMA miniature swines were numbered from 1 to 24 and randomly divided by EXCEL 2007 into 4 groups of succinylated gelatin, hydroxyethyl starch (HES 130/0.4), Parkland (lactated Ringer's solution) and allogeneic plasma (n = 6 each). The model of severe burn shock was established. And fluid resuscitation therapy was applied according to the established regimens of burn shock fluid resuscitation. The parameters of heart rate, blood pressure, urine volume, central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) were recorded. Blood samples were collected prior to burns and at intervals of 4, 8, 24 and 48 h post-burns. The plasma colloidal osmotic pressure was measured. Evens blue was intravenously injected at 30 min before sacrificing. Then lung tissue samples were obtained and pulmonary vascular permeability index (PMPI) was measured. Statistical analyses were performed. All swines survived shock stage. The inter-group comparison revealed no statistical difference in heart rate, blood pressure, urine volume, CVP or PCWP. The plasma colloidal osmotic pressures (mmHg, 1 mmHg = 0.133 kPa) of four groups at each interval were as follows: (1) pre-burn: 25.4 ± 1.0, 25.9 ± 0.9, 25.5 ± 1.1, 25.0 ± 1.0; (2) 4 h: 24.3 ± 1.0, 25.6 ± 0.9, 13.2 ± 0.5, 25.0 ± 1.1; (3) 8 h: 23.3 ± 0.8, 25.2 ± 1.2, 12.7 ± 0.5, 24.0 ± 0.9; (4) 24 h: 22.0 ± 0.8, 23.1 ± 1.0, 12.4 ± 0.4, 23.3 ± 0.8; (5) 48 h: 22.3 ± 0.8, 24.1 ± 0.8, 18.1 ± 0.4, 23.5 ± 0.9. No statistically significant differences existed at the intervals of pre-burn between four groups (all P > 0.05). The HES 130/0.4 group at 8 h was significantly higher than that of allogeneic plasma group at the same interval (P < 0.05). The Parkland group at 4, 8, 24, 48 h were significantly lower than those of allogeneic plasma group (all P < 0.05). The succinylated gelatin group at 8, 24, 48 h, the HES 130/0.4 group at 8, 24, 48 h, the Parkland group at 4, 8, 24, 48 h and allogeneic plasma at 8, 24, 48 h decreased versus those at pre-burns (all P < 0.05). No statistically significant differences existed in pulmonary vascular permeability between the groups of succinylated gelatin (7.6 ± 0.9) µg/g, HES 130/0.4 (7.9 ± 1.8) µg/g, and allogeneic plasma (7.6 ± 1.2) µg/g, but all lower than the Parkland group (26.1 ± 2.3) µg/g (all P < 0.05). Natural colloid or artificial colloid (HES 130/0.4 or succinylated gelatin) have similar effects on vascular permeability in swines with severe burns during shock stage. Both are superior to the Parkland group.

The Use of Limited Fluid Resuscitation and Blood Pressure-Controlling Drugs in the Treatment of Acute Upper Gastrointestinal Hemorrhage Concomitant with Hemorrhagic Shock.

The aim of this study was to evaluate the usefulness of the limited fluid resuscitation regimen combined with blood pressure-controlling drugs in treating acute upper gastrointestinal hemorrhage concomitant with hemorrhagic shock. A total of 51 patients were enrolled and divided into a group that received traditional fluid resuscitation group (conventional group, 24 patients) and a limited fluid resuscitation group (study group, 27 patients). Before and after resuscitation, the blood lactate, base excess, and hemoglobin values, as well as the volume of fluid resuscitation and resuscitation time were examined. Compared with conventional group, study group had significantly better values of blood lactate, base excess, and hemoglobin (all p<0.05). In addition, both volume of fluid resuscitation and resuscitation time were significantly (p<0.05) lower in these patients. Limited fluid resuscitation combined with blood pressure-controlling drugs effectivelyxxx maintains blood perfusion of vital organs, improves whole body perfusion indicators, reduces the volume of fluid resuscitation, and achieves better bleeding control and resuscitation effectiveness.

Effects on ischemia-reperfusion injury with different fluid resuscitation regimens during burn shock stage in swines

To explore the effects on ischemia-reperfusion injury with different regimens of fluid resuscitation during severe burn shock stage in swines. A total of 24 Guangxi BA-MA mini-swine were numbered from 1 to 24 and randomly divided by EXCEL 2007 into 4 groups of succinylated gelatin, hydroxyethyl starch (HES 130/0.4), Parkland and allogeneic plasma (n = 6 each). Then the burn shock model was established. And fluid resuscitation therapy was applied according to the established regimens of burn shock fluid resuscitation. Blood samples were collected from the animals prior to burn injury and again at intervals of 4, 8, 24 and 48 hours post-injury. The levels of malondialdehyde, superoxide dismutase (SOD), xanthine oxidase (XOD) and total antioxidant capacity (T-AOC) were measured. And the results were analyzed statistically. Six swines within each group survived the shock stage and the outliers in detection index were eliminated. Then there were 5 swines in each group. The MDA of allogeneic plasma group at intervals of 8 hours was significantly lower than that of succinylated gelatin group, but higher than that of Parkland group [(3.46 ± 0.40) vs (4.55 ± 0.82), (2.59 ± 0.35) µmol/L, both P < 0.05]. The level of SOD had statistical difference at 48 hours between the HES 130/0.4 and allogeneic plasma groups ((72.55 ± 5.70) vs (65.42 ± 5.07) U/ml, P < 0.05). The level of XOD of the succinylated gelatin group at 4, 8 hour and they increased when compared to pre-burn ((12.00 ± 0.57), (11.28 ± 0.71) vs (9.12 ± 0.51) U/L, both P < 0.01).Statistical significance was observed at 4, 8 hours between succinylated gelatin and allogeneic plasma groups ((10.39 ± 1.24), (9.59 ± 1.17) U/L, both P < 0.01). The T-AOC of HES 130/0.4 group at 8 hours exceed the pre-burn ((2.06 ± 0.43) vs (1.30 ± 0.35) U/ml, P < 0.05). The allogeneic plasma group at 4, 8 hours showed increase when compared to pre-burn ((1.55 ± 0.37), (2.59 ± 0.60) vs (1.06 ± 0.13) U/ml, both P < 0.05). The succinylated gelatin group at 8, 48 hours decreased during the corresponding phase of allogeneic plasma group ((1.14 ± 0.26), (0.89 ± 0.20) vs (2.59 ± 0.60), (1.16 ± 0.20) U/ml, both P < 0.05). The comparison at 24, 48 hours between HES 130/0.4 and allogeneic plasma groups ((1.84 ± 0.41), (1.53 ± 0.21) vs (1.13 ± 0.35), (1.16 ± 0.20) U/ml) had statistical difference (both P < 0.01). The Parkland group at intervals of 8 hours was lower than that of allogeneic plasma group ((1.31 ± 0.19) vs (2.59 ± 0.60) U/ml, P < 0.01). HES130/0.4 and allogeneic plasma have comparable the parallel minimum damage effect on ischemia-reperfusion injury during burn shock stage are.

Uncontrolled hemorrhagic shock results in a hypercoagulable state modulated by initial fluid resuscitation regimens

Previous studies have shown large-volume resuscitation modulates coagulopathy and inflammation. Our objective was to analyze the effects of initial bolus fluids used in military and civilian settings on coagulation and inflammation in a prospective, randomized, blinded trial of resuscitation of uncontrolled hemorrhage. Fifty swine were anesthetized, intubated, and ventilated and had monitoring lines placed. A Grade V liver injury was performed followed by 30 minutes of hemorrhage. After 30 minutes, the liver was packed, and randomized fluid resuscitation was initiated during a 12-minute period with 2 L of normal saline, 2 L of lactated Ringer's solution, 250 mL of 7.5% saline with 3% Dextran, 500 mL of Hextend, or no fluid (NF). Animals were monitored for 2 hours after injury. Thrombelastograms (TEGs), prothrombin time (PT), partial thromboplastin time, fibrinogen as well as serum interleukin 6, interleukin 8, and tumor necrosis factor α levels were drawn at baseline and after 1 hour and 2 hours. The NF group had less posttreatment blood loss compared with other groups (p < 0.01). Blood loss was similar in the other groups. TEG R values in each group decreased from baseline at 1 and 2 hours (p < 0.02). The groups receiving 2 L of normal saline, 250 mL of 7.5% saline with 3% Dextran, or 500 mL of Hextend had lower TEG maximum amplitude values compared with NF group (p < 0.02). All fluids except lactated Ringer's solution resulted in significant increases in PT compared with NF, whereas all fluids resulted in significant decreases in fibrinogen compared with NF (p < 0.02). Fluid resuscitation groups as well as NF group demonstrated significant increases in inflammatory cytokines from baseline to 1 hour and baseline to 2 hours. There were no significant differences in inflammatory cytokines between groups at 2 hours. Withholding fluid resulted in the least significant change in PT, fibrinogen, and maximum amplitude and in the lowest posttreatment blood loss. Resuscitation with different initial fluid resuscitation strategies did not result in increased proinflammatory mediators compared with animals that did not receive fluid.

Hemodilution as a result of aggressive fluid resuscitation aggravates coagulopathy in a rat model of uncontrolled hemorrhagic shock

The relationship between dilution caused by fluid resuscitation and blood coagulability during ongoing, uncontrolled hemorrhagic shock (UHS) remains unclear. We hypothesized that dilution caused by fluid resuscitation may impair blood coagulability in UHS. Eighteen rats underwent under halothane anesthesia. The UHS model consisted of the following phases: (1) an initial blood withdrawal of 2.5 mL per 100 g during 15 minutes, followed by UHS via tail amputation and fluid resuscitation with lactated Ringer's (LR) solution (0-60 minutes); (2) hemostasis and reinfusion of withdrawn blood and additional LR solution (60-100 minutes); and (3) observation of awake rats for 72 hours. Rats were randomized into three resuscitation regimens (n = 6 per group) during Phase I. LR solution was infused at a rate of 0.1 mL/min in Group 1, 0.25 mL/min in Group 2, and 0.75 mL/min in Group 3. Blood coagulability was assessed with a Sonoclot analysis, and survival to 72 hours were compared between groups. Both resuscitation regimens of Groups 2 and 3 increased the blood pressure and bleeding volume from the tail stump compared with Group 1 (p < 0.05). At the end of Phase I, the hematocrit decreased to 29% (3%) in Group 1, 23% (3%) in Group 2, and 12% (3%) in Group 3 (p < 0.05). Sonoclot analysis revealed a decreased clot rate of 16 (9) clot signal per minute in Group 2 and 14 (10) clot signal per minute in Group 3 compared with Group 1 (40 [10] clot signal per minute; p < 0.01). There was a significant correlation between clot rate and hematocrit values (r = +0.67, p < 0.01). Compared with Group 1, survival improved in Groups 2 and 3 (p < 0.05). In a rat model of UHS, aggressive fluid resuscitation aggravated hemodilution and blood coagulability as well as and bleeding but improved the hemodynamics and survival. There was a positive correlation between hemodilution and coagulation indexes. Hemodilution, as part of fluid therapy, may affect coagulopathy in UHS.