The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategy

Division of Trauma and Surgical Critical Care, Vanderbilt University, Нашвилл, Michigan, United States
Shock (Impact Factor: 3.05). 09/2006; 26(2):115-21. DOI: 10.1097/01.shk.0000209564.84822.f2
Source: PubMed


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.

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Available from: Bryan A Cotton, Sep 02, 2014
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    • "Animal and human data support this strategy in the pre-hospital and ED resuscitation phases until definitive haemostasis achieved by surgery or angiography is performed, or defined as not required (Bickell et al., 1994; Dutton et al., 2002; Mapstone et al., 2003; Morrison et al., 2011). The previous paradigm of high volume crystalloid-based resuscitation was associated with higher volumes of blood loss, impaired coagulation, impaired organ perfusion and mortality excess (Cotton et al., 2006; Lefering and Taeger, 2011; Smail et al., 1998). Consequently, the National Institute for Clinical Excellence in the UK has recommended that pre-hospital 250 mL fluid boluses be delivered in adults and older children with blunt trauma when radial pulse is lost, and with loss of central pulses for penetrating disease (National Institute for Clinical Excellence, 2004). "
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    ABSTRACT: Worldwide, trauma is responsible for more than 10,000 deaths each day with hundreds of thousands seriously injured. Current trauma resuscitation strategies are based on supporting haemostasis, maintaining circulating volume and rapidly identifying sites of blood loss. Approaches include hypotensive/hypovolaemic resuscitation, avoidance of colloids and crystalloids, early blood product based resuscitation, early imaging to identify sites of blood loss and damage control surgery. In this paper, we focus on ways to minimise blood loss and preserve the circulating volume. These include minimal movement of the patient, splinting fractures, use of tourniquets, application of local haemostatic dressings/agents, keeping the patient warm and giving tranexamic acid to improve clot strength. The recent CRASH-2 trial provided unequivocal evidence that tranexamic acid reduces mortality in bleeding trauma patients. This will be discussed in detail. When employed as part of a package of care in a well-rehearsed trauma system, these interventions to preserve the remaining circulating volume have the potential to save lives and allow patients to survive until timely definitive haemostasis can occur.
    Preview · Article · Dec 2013 · Trauma
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    • "Hemodynamic derangements due to hypovolemic shock should be reversed as quickly as possible with volume resuscitation. However, over use of crystalloids can result in third spacing worsening bowel edema, anastomotic leaks, ACS and multi-organ failure [59,60]. Accordingly, the use of massive transfusion protocols (MTP) has been recommended for DCL patients [60-62]. "
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    ABSTRACT: Damage control laparotomy was first described by Dr. Harlan Stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room for definitive repair. The term damage control in the trauma setting was coined by Rotondo et al., in 1993. Studies in subsequent years have validated this technique by demonstrating decreased mortality and immediate post-operative complications. The indications for damage control laparotomy have evolved to encompass abdominal compartment syndrome, abdominal sepsis, vascular and acute care surgery cases. The perioperative critical care provided to these patients, including sedation, paralysis, nutrition, and fluid management strategies may improve closure rates and recovery. In the rare cases of inability to primarily close the abdomen, there are a number of reconstructive strategies that may be used in the acute and chronic phases of abdominal closure.
    Full-text · Article · Dec 2013 · World Journal of Emergency Surgery
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    • "Finally, in the late 1990s clinicians started realizing the deleterious effects of excess crystalloid [11,12]. This led to a return to the balanced resuscitation that was reminiscent of that described in the Second World War. "
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    ABSTRACT: Traumatic injury is a common problem, with over five million worldwide deaths from trauma per year. An estimated 10 to 20% of these deaths are potentially preventable with better control of bleeding. Damage control resuscitation involves early delivery of plasma and platelets as a primary resuscitation approach to minimize trauma-induced coagulopathy. Plasma, red blood cell and platelet ratios of 1:1:1 appear to be the best substitution for fresh whole blood; however, the current literature consists only of survivor bias-prone observational studies.
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