ABSTRACT To review the clinical aspects of hemorrhagic shock and provide recommendations for therapy.
Early recognition of hemorrhagic shock and prompt systematic intervention will help avoid poor outcomes.
Establish guidelines to assist in early recognition of hemorrhagic shock and to conduct resuscitation in an organized and evidence-based manner.
Medline references were sought using the MeSH term "hemorrhagic shock." All articles published in the disciplines of obstetrics and gynaecology, surgery, trauma, critical care, anesthesia, pharmacology, and hematology between 1 January 1990 and 31 August 2000 were reviewed, as well as core textbooks from these fields. Selected references from these articles and book chapters were also obtained and reviewed. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.
1. Clinicians should be familiar with the clinical signs of hemorrhagic shock. (III-B) 2. Clinicians should be familiar with the stages of hemorrhagic shock. (III-B) 3. Clinicians should assess each woman's risk for hemorrhagic shock and prepare for the procedure accordingly. (III-B) 4. Resuscitation from hemorrhagic shock should include adequate oxygenation. (II-3A) 5. Resuscitation from hemorrhagic shock should include restoration of circulating volume by placement of two large-bore IVs, and rapid infusion of a balanced crystalloid solution. (I-A) 6. Isotonic crystalloid or colloid solutions can be used for volume replacement in hemorrhagic shock (I-B). There is no place for hypotonic dextrose solutions in the management of hemorrhagic shock (I-E). 7. Blood component transfusion is indicated when deficiencies have been documented by clinical assessment or hematological investigations (II-2B). They should be warmed and infused through filtered lines with normal saline, free of additives and drugs (II-3B). 8. Vasoactive agents are rarely indicated in the management of hemorrhagic shock and should be considered only when volume replacement is complete, hemorrhage is arrested, and hypotension continues. They should be administered in a critical care setting with the assistance of a multidisciplinary team. (III-B) 9. Appropriate resuscitation requires ongoing evaluation of response to therapy, including clinical evaluation, and hematological, biochemical, and metabolic assessments. (III-B) 10. In hemorrhagic shock, prompt recognition and arrest of the source of hemorrhage, while implementing resuscitative measures, is recommended. (III-B)VALIDATION: These guidelines have been reviewed by the Clinical Practice Obstetrics Committee and approved by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.
The Society of Obstetricians and Gynaecologists of Canada.
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ABSTRACT: Hydroxyethyl starch (HES) is a synthetic colloid used widely for resuscitation despite the availability of safer, less costly fluids. Numerous HES reviews have been published that may have influenced clinicians' practice. We have therefore examined the relationship between the methodological quality of published HES reviews, authors' potential conflicts of interest (pCOI) and the recommendations made. Systematic analysis of reviews on HES use. Between 1975 and 2010, 165 reviews were published containing recommendations for or against HES use. From the 1990s onwards, favorable reviews increased from two to eight per year and HES's share of the artificial colloid market tripled from 20 to 60 %. Only 7 % (12/165) of these reviews of HES use contained meta-analyses; these 7 % had higher Overview Quality Assessment Questionnaire (OQAQ) scores [median (range) 6.5 (3-7)] than reviews without meta-analysis [2 (1-4); p < 0.001]. The rates of recommending against HES use are 83 % (10/12) in meta-analyses and 20 % (31/153) in reviews without meta-analysis (p < 0.0001). Fourteen authors published the majority (70/124) of positive reviews, and ten of these 14 had or have since developed a pCOI with various manufacturers of HES. Low-quality HES reviews reached different conclusions than high-quality meta-analyses from independent entities, such as Cochrane Reviews. The majority of these low-quality positive HES reviews were written by a small group of authors, most of whom had or have since established ties to industry. The proliferation of positive HES reviews has been associated with increased utilization of an expensive therapy despite the lack of evidence for meaningful clinical benefit and increased risks. Clinicians need to be more informed that marketing efforts are potentially influencing scientific literature.European Journal of Intensive Care Medicine 07/2012; 38(8):1258-71. · 5.17 Impact Factor
Article: [Obstetric bleeding: an update].[Show abstract] [Hide abstract]
ABSTRACT: Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.Revista espanola de anestesiologia y reanimacion 04/2010; 57(4):224-35.
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ABSTRACT: Haemorrhagic shock occasionally causes an episode of lung dysfunction, the severity of which appears to correlate with fatal outcome. Our previous study indicated that proinflammatory cytokines, such as tumour necrosis factor (TNF)-alpha and interleukin (IL)-1beta, played a key role in the development of lung dysfunction through recruitment of activated neutrophils by causing pulmonary endothelial cell damage. Here, we examined this issue quantitatively by grading four groups of severity of bleeding in rats. As the amount of bleeding increased, the expression of mRNA for TNF-alpha and IL-1beta in the lung tissue and the pulmonary serum levels of both cytokines increased progressively up to 5 h, and the frequency of activated neutrophils increased likewise. The lung dysfunction indices serum lactic dehydrogenase-3 isozyme (LDH-3), partial pressure of arterial oxygen (PaO(2)) and alveolar-arterial oxygen tension difference (AaDO(2)) in blood deteriorated as the amount of bleeding increased. The frequency of activated neutrophils in the lung correlated well with the LDH-3 level 5 h after haemorrhagic shock. The present results demonstrate that the increase of proinflammatory cytokines and the recruitment of activated neutrophils into the lung following haemorrhagic shock are quantitatively related to progression of lung dysfunction as the amount of bleeding increases.International Journal of Experimental Pathology 01/2009; 91(3):267-275. · 2.04 Impact Factor