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PubMed1997

Superiority of blood over saline resuscitation from hemorrhagic shock: a 31P magnetic resonance spectroscopy study.

OBJECTIVE: To study the relation between blood and saline administration, postresuscitation hematocrit (Hct) level, and metabolic recovery after hemorrhagic shock. SUMMARY BACKGROUND DATA: It is generally believed that crystalloid can be substituted, in whole or in part, for blood during resuscitation of hemorrhagic shock. This is based on the belief that Hct can be safely reduced but should not fall below a critical level. METHODS: Male rats weighing 200 g were subjected to an isobaric hemorrhagic shock at a mean arterial pressure of 30 mmHg for 14 minutes, after which they were randomized to one of three resuscitation regimens. Control group (n = 36) were resuscitated by return of all shed blood. Mid-Hct (n = 39) and low-Hct (n = 60) groups were depleted of one third and one half of their circulating blood volumes, respectively, and were resuscitated with three times that volume of normal saline. Skeletal muscle intracellular energetics and pH were measured serially using 31P magnetic resonance spectroscopy at baseline, during shock, and after resuscitation. Arterial blood was sampled at the same time points. The number of surviving animals in each group at 24 hours was recorded. RESULTS: After resuscitation, surviving rats in the low-Hct group demonstrated a greater consumption of high-energy phosphocreatine stores than did the other groups (control = 0.479 +/- 0.003, mid-Hct = 0.465 +/- 0.004, low-Hct = 0.457 +/- 0.007, mean +/- standard error of the mean; p < 0.01 low-Hct vs. other groups by analysis of variance). The rats that received saline resuscitation developed a relative intracellular acidosis (control = 7.29 +/- 0.02, mid-Hct = 7.25 +/- 0.02, low-Hct = 7.23 +/- 0.02; p < 0.05 controls vs. other groups by analysis of variance). At 24 hours, the death rates were significantly different among the groups: control = 1 of 36 rats (2.8%), mid-Hct = 6 of 39 (15.4%), and low-Hct = 14 of 60 (23.3%) (p < 0.05 by chi square analysis). CONCLUSION: The oxygen-carrying capacity of resuscitation fluid has an important impact on intracellular metabolism and outcome.

Animals↗
PubMed1979

Relative importance of alpha and beta adrenergic receptors during resuscitation.

Successful resuscitation from cardiac arrest in the asphyxiated dog model has been ascribed to the use of artificial ventilation, closed chest cardiac massage, and administration of a vasopressor. Controversy remains over whether the most commonly employed vasopressor, epinephrine, exerts its effects primarily by elevating diastolic pressure and reestablishing coronary flow, or by exciting cardiac pacemaker cells and enhancing myocardial contractility. To observe pure alpha and beta adrenergic receptor influences during resuscitation, three groups (alpha-blocked, beta-blocked, unblocked) of dogs were studied. beta-blocked dogs resuscitated with phenylephrine and unblocked dogs resuscitated with epinephrine experienced 100% successful resumption of spontaneous circulation after 5 min of asphyxia-induced arrest. Only 27% of alpha-blocked animals resuscitated with isoproterenol were successfully revived. The appearance of the ECG during cardiac arrest and resuscitation could in no way be used to predict the outcome of resuscitation attempts. Results suggest that, initially, alpha receptor stimulation with concomitant diastolic pressure elevation is more important to the success of resuscitation than beta receptor stimulation.

Animals↗
PubMed1983

Clinical aspects of resuscitation with and without an algorithm: relative importance of various decisions.

Clinical description was made of a series of hypotensive patients resuscitated with and without an algorithm. Of 603 hypotensive patients, there were 114 (19%) deaths and 169 (28%) patients with complications; the average low MAP was 53 +/- 25 mm Hg. Of 169 patients with complications, 48 (28%) had shock-related (SR) complications; 25 (52%) of these patients died. There were 265 (44%) patients who had severe associated diseases and these patients comprised the group most vulnerable to complications and death; in this group, there were 41 patients with SR-complications who had significantly higher mortality, longer resuscitation times, lower MAP, more deviations from the algorithm, and more delays in resuscitation than did those with nonshock-related complications. Multiple deviations from the algorithm were associated with longer resuscitation times, and higher incidence of SR complications. Most of the delays in resuscitation of these patients and most of the SR complications could have been prevented. Seventeen percent of hypotensive patients entering the emergency department (ED) normally carried low arterial pressures, which averaged 75 +/- 3 (SD) mm Hg; this was more common, but not confined to young females. Of the 603 patients who actually were hypotensive, 6% were admitted in arrest (phase I), 18% in severe shock (phase II, MAP less than 60 mm Hg), 52% in moderate shock (phase III, MAP less than 80 mm Hg), and 24% were normotensive but subsequently became hypotensive (phase IV). The importance of various decision nodes of the algorithm were evaluated. The present algorithm, designed for these hypotensive emergency patients, provides a framework for fluid management that expedites resuscitation and reduces complications related to shock. We conclude that: (a) delays in resuscitation can be clearly related to an increased incidence of SR complications; (b) when the algorithm was satisfactorily followed, there was faster resuscitation and less SR complications; and (c) when the algorithm was satisfactorily followed in patients with severe associated illnesses, there was also shorter ICU stay, shorter hospitalization and decreased mortality.

Adolescent↗
PubMed1985

Effects on intracranial pressure of resuscitation from hemorrhagic shock with hypertonic saline versus lactated Ringer's solution.

Hypertonic saline (2400 mOsm/L) has been used successfully for fluid resuscitation of dogs subjected to severe hemorrhagic shock. This study compared the effects of resuscitation with hypertonic saline vs. lactated Ringer's solution on intracranial pressure (ICP) in dogs subjected to 30 min of sustained hypovolemic shock. Hypotension was produced by rapid withdrawal of blood until mean arterial pressure was 50 mm Hg, maintained at that level by withdrawal or infusion of blood over the next 30 min as necessary. Eight animals were resuscitated with hypertonic saline solution and nine with lactated Ringer's solution. Both solutions restored systolic blood pressure and cardiac output to control values. However, diastolic blood pressure and mean arterial pressure did not return to control values. The most prominent difference between the two groups was in ICP measured after resuscitation. ICP was lower in dogs resuscitated with hypertonic saline than in dogs resuscitated with lactated Ringer's solution (p = .029). Hypertonic saline fluid resuscitation may represent a potential alternative when aggravation of intracranial hypertension during resuscitation would place a patient at greater risk.

Analysis of Variance↗
PubMed1989

Plasma catecholamines and resuscitation from prolonged cardiac arrest.

Plasma catecholamine levels rise markedly with cardiac arrest and attempted resuscitation. We examined whether epinephrine (EPI) or norepinephrine (NE) plasma concentrations could predict resuscitation outcome. In nine mongrel dogs, EPI and NE levels were drawn before cardiac arrest and after 8 and 14 min of cardiac arrest and CPR. Intravenous EPI (1 mg) was given 1 min before the last plasma level was drawn. Catecholamines were quantitated by high-performance liquid chromatography with triple-electrode coulometric electrochemical detection. Plasma catecholamines increased significantly with cardiac arrest, EPI levels increased from a control level of 15.9 +/- 3.0 to 396.0 +/- 63.3 pmol/ml after 8 min of cardiac arrest (p less than .05), and NE levels similarly increased from 4.4 +/- 1.7 to 66.5 +/- 12.0 pmol/ml (p less than .01). Neither the absolute catecholamine plasma concentration nor the response to cardiac arrest of the endogenous catecholamine concentrations could predict outcome, but catecholamine responses to exogenous EPI did correlate with outcome. Animals which were subsequently resuscitated had a greater increase in the plasma EPI concentrations after exogenous EPI than animals that were not resuscitated, a 53-fold vs. a 23-fold increase (p less than .05). Successfully resuscitated animals also had increased NE levels after exogenous EPI, while unsuccessfully resuscitated animals had either no change or a decrease (p less than .02). Successfully resuscitated animals had an increase in coronary perfusion pressure (p less than .01) in response to exogenous EPI, in contrast to those that were not resuscitated. This suggests that the exogenous administration of EPI during prolonged CPR is beneficial despite markedly elevated endogenous catecholamine levels.

Animals↗
PubMed1996

Small-volume resuscitation restores hemorrhage-induced microcirculatory disorders in rat pancreas.

OBJECTIVES: Pancreatic hypoxia/ischemia, as a consequence of shock-induced microcirculatory failure, is considered a causative factor in the initiation and/or progression of pancreatic tissue injury. The aim of this study was to compare the effects of "small volume resuscitation" with conventional isovolemic colloid and hypervolemic crystalloid resuscitation on pancreatic microcirculation after hemorrhagic shock. DESIGN: Randomized, controlled intervention trial. SETTING: University laboratory. SUBJECTS: Twenty-three male Sprague-Dawley rats anesthetized with á-chloralose mechanically and ventilated. INTERVENTIONS: Rats subjected to 1 hr of hemorrhagic shock (mean arterial pressure of 40 mm Hg) were resuscitated with lactated Ringer's solution (four-fold shed volume/20 mins), 10% hydroxyethyl starch (shed volume/5 mins), or 7.2% sodium chloride-10% hydroxyethyl starch (10% shed volume/2 mins). MEASUREMENTS AND MAIN RESULTS: The microcirculation of pancreatic acinar tissue was studied by means of intravital fluorescence microscopy and laser Doppler flowmetry. At 1 hr after resuscitation, mean arterial pressure, pancreatic capillary erythrocyte velocity, and erythrocyte flux were found to be significantly increased when compared with those values in the shock state. However, mean arterial pressure, pancreatic capillary erythrocyte velocity, and erythrocyte flux did not completely return to preshock values, regardless of the type of fluid used for resuscitation. At 15 mins and 1 hr after resuscitation, shock-induced capillary perfusion failure (reduction of functional capillary density) was restored to 91% to 94% of baseline values in all groups. Pancreatic capillary narrowing, indicating microvascular endothelial cell swelling, was abolished by resuscitation with both isotonic hydroxyethyl starch and hypertonic hydroxyethyl starch (p<.05 vs. lactated Ringer's solution). CONCLUSIONS: Despite replacement of only 10% of actual blood loss, small-volume resuscitation with hypertonic hydroxyethyl starch is as effective as the ten-fold volume of isotonic hydroxyethyl starch and, due to prevention of microvascular endothelial cell swelling, superior to the 40-fold volume of isotonic lactated Ringer's solution in regard to restoration of the shock-induced microcirculatory disturbances of rat pancreatic acinar tissue.

Analysis of Variance↗
PubMed1996

Cerebral effects of resuscitation with hypertonic saline and a new low-sodium hypertonic fluid in hemorrhagic shock and head injury.

OBJECTIVES: A 2400-mOsm/L hypertonic solution (isosal) with a lower sodium content, compared with conventional 7.5% hypertonic saline, was formulated using a mixture of sodium chloride, glucose, and mixed amino acids. This solution was developed to minimize hypernatremia during resuscitation. We assessed the effects of isosal on hemodynamics, brain edema, and plasma sodium concentration after head injury associated with hemorrhagic shock. DESIGN. Prospective, randomized laboratory study. SETTING: University research laboratory. SUBJECTS: Twenty-one adult female Suffolk sheep, weighing 39 to 49 kg. INTERVENTIONS: Animals were subjected to a 2-hr period of hemorrhagic shock to a mean arterial pressure (MAP) of 40 to 45 mm Hg in the presence of a freeze injury to the cerebral cortex. The hemorrhagic shock/head injury phase was followed by 2 hrs of resuscitation with isosal, a new 2400-mosm/L low-sodium hypertonic fluid, 2400 mosm/L of 7.5% hypertonic saline, or lactated Ringer's solution. Initial resuscitation was with a bolus injection of 8 mL/kg of the study solution; subsequent resuscitation in all three groups was with lactated Ringer's solution as needed to maintain baseline cardiac output. MEASUREMENTS AND MAIN RESULTS: Serial hemodynamics, intracranial pressure, electrolytes, and osmolarity were measured. AT the end of resuscitation, the animals were killed and brain water content (mL H2O/g dry weight) of the injured and uninjured areas was determined. Resuscitation volumes were significantly lower in the isosal (19 +/- 5 mL/kg) and 7.5% hypertonic saline (14 +/- 2 mL/mg) groups compared with the lactated Ringer's solution (35 +/- 5 mL/kg) group. Intracranial pressure after 2 hrs of resuscitation was significantly lower in the isosal (7 +/- 1 mm Hg) and hypertonic saline groups (4 +/- 1 mm Hg). Water content in all areas of the brain was significantly lower in the hypertonic saline group compared with the lactated Ringer's solution group. Brain water content in the isosal group was lower than in the lactated Ringer's solution group only in the cerebellum. Plasma sodium content was lower in the isosal group than in the hypertonic saline group. CONCLUSIONS: After combined head injury and shock, isosal and 7.5% hypertonic saline have similar effects on hemodynamics and intracranial pressure. Hypertonic saline induces a greater degree of brain dehydration; isosal resuscitation results in smaller increases in plasma sodium.

Animals↗
PubMed1996

Extramyocardial acidosis impairs cardiac resuscitability in isolated, perfused, rat hearts.

OBJECTIVES: Patients suffering out-of-hospital cardiac arrest have various degrees of acidemia when cardiopulmonary resuscitation is initiated. Myocardial hypercarbia, rather than decreases in myocardial pH, may determine cardiac resuscitability. Accordingly, we questioned whether different degrees of acidemia accompanying cardiac arrest affect cardiac resuscitability. We evaluated the effect of different degrees of extramyocardial acidosis on cardiac performance and resuscitability after ventricular fibrillation using isolated, perfused, rat hearts. DESIGN: Prospective, randomized, controlled study. SETTING: Experimental animal laboratory in a university hospital. SUBJECTS: Thirty-one male, Sprague-Dawley rats. INTERVENTIONS: Rat hearts were perfused with N-[2-hydroxyethyl]piperazine-N-[2-ethanesulfonic acid] (HEPES) buffered solution (sodium chloride 145 mM, potassium chloride 4 mM, sodium dihydrogen phosphate dihydrate 1.25 mM, magnesium chloride 1.5 mM, calcium chloride 2 mM, HEPES 6 mM, glucose 10 mM), which was bubbled with 100% oxygen and adjusted to a pH of 7.4. The perfusion pressure was held constant at 60 mm Hg. After 60 mins of stabilization, the control perfusion solution was switched to one of the solutions titrated to pH 6.2, 6.5, 6.8, 7.1, or 7.4, using 1 N of sodium hydroxide. Hearts were allocated randomly to each group. After 15 mins of perfusion, the perfusion was discontinued, and artificial ventricular fibrillation was induced by electrical stimulation for 5 mins. The hearts were then perfused again in one of the same acidotic solutions for 30 mins. MEASUREMENTS AND MAIN RESULTS: Left ventricular developed pressure (left ventricular pressure minus end-diastolic left ventricular pressure), positive change in left ventricular pressure over time, heart rate (HR), and coronary flow were continuously measured. After 60 mins of stabilization, the values of left ventricular developed pressure, positive change in left ventricular pressure over time, HR, and coronary flow were not significantly different between groups. After 5 mins of ventricular fibrillation, all hearts were asystolic and left ventricular developed pressure, positive change in left ventricular pressure over time, HR, and coronary flow were all zero. After 30 mins of reperfusion, all values in the acidotic groups were significantly lower than the values in the pH 7.4 group. When we judged the recovery of left ventricular developed pressure at > 35 mm Hg as "resuscitated," resuscitability was impaired at a pH of < 7.1. No hearts recovered after perfusion below a pH of 6.5. CONCLUSIONS: Extramyocardial acidosis below pH 7.1 decreased cardiac performance and resuscitability after ventricular fibrillation. This result indicates that progressive acidemia during cardiac arrest is one of the important determinants of cardiac resuscitability.

Acidosis↗
PubMed1999

Acid-base status of blood from intraosseous and mixed venous sites during prolonged cardiopulmonary resuscitation and drug infusions.

OBJECTIVES: a) To determine the relationship of acid-base balance (pH, PCO2) of blood samples from the intraosseous and the mixed venous route during prolonged cardiopulmonary resuscitation; b) to compare the effect of separate infusions of epinephrine, fluid boluses, or sodium bicarbonate through the intraosseous sites on the acid-base status of intraosseous and mixed venous blood during cardiopulmonary resuscitation; and c) to compare pH and Pco2 of intraosseous and mixed venous blood samples after sequential infusions of fluid, epinephrine, and sodium bicarbonate through a single intraosseous site. DESIGN: Prospective, randomized study. SETTING: Animal laboratory at a university center. SUBJECTS: Thirty-two mixed-breed piglets (mean weight, 30 kg). INTERVENTIONS: Piglets were anesthetized and prepared for blood sampling and cardiopulmonary resuscitation. After anoxic cardiac arrest, ventilation was resumed and chest compression was resumed. Blood gas samples from the pulmonary artery and both intraosseous sites were obtained simultaneously at baseline, at cardiac arrest, and at 5, 10, 15, 20, and 30 mins of cardiopulmonary resuscitation for group 1 (control group) and after drug (epinephrine and sodium bicarbonate) and saline infusions via one of the intraosseous cannulas in groups 2 through 5. MEASUREMENTS AND MAIN RESULTS: We found no differences between intraosseous and mixed venous pH and Pco2 during periods of <15 mins of cardiopulmonary resuscitation. However, this relationship was not maintained during prolonged cardiopulmonary resuscitation and after bicarbonate infusion. After large volume saline infusion, the pH and Pco2 of mixed venous and intraosseous blood were similar. During epinephrine infusion, the relationship between intraosseous and mixed venous pH and Pco2 was similar to that found in the control group. CONCLUSIONS: The intraosseous blood sample could be used to assess central acid-base balance in the early stage of arrest and cardiopulmonary resuscitation of <15 mins. However, during cardiopulmonary resuscitation of longer duration, drug infusions may render the intraosseous site inappropriate for judging central acidosis.

Acid-Base Equilibrium↗
PubMed1989

A comparison of the cerebral and cardiovascular effects of complete resuscitation with isotonic and hypertonic saline, hetastarch, and whole blood following hemorrhage.

Hemorrhagic shock and closed head injury often accompany severe trauma. Hypertonic saline may be beneficial in these patients, but few have examined its properties when sufficient volume is infused to achieve sustained resuscitation. Solutions of 6% NaCl (HS), 0.9% NaCl (NS), 6% hetastarch (HE), and whole blood (WB) were used to resuscitate swine in hemorrhagic shock (MAP less than 30 mm Hg). The endpoint of resuscitation was normal oxygen delivery (DO2). Measurements of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and intracranial elastance (ICE) were made in the absence and presence of an epidural mass, created by inflating an epidural balloon. HS resuscitation resulted in a lower ICP [5 +/- 1 versus 9 +/- 2 (HE), 17 +/- 3 (NS), and 10 +/- 3 (WB) mm Hg; p = 0.016], and normalization of CPP throughout resuscitation. Animals resuscitated with NS had a lower CPP by the end of resuscitation [CPP = 45 +/- 4 for NS group, versus 63 +/- 4 (HE), 66 +/- 4 (HS), and 63 +/- 5 (WB) mm Hg; p = 0.009]. ICE fell markedly in the HS group, [a decrease of 12 +/- 2 vs. a rise of 5 +/- 3 (HE), 2 +/- 3 (NS), and 6 +/- 3 (WB) mm Hg/ml; p = 0.0005]. This improvement was even more dramatic in the presence of an epidural mass [a fall of 21 +/- 3 vs. no change (HE, WB) and a rise of 4 +/- 3 (NS) mm Hg/ml; p = 0.0005]. For hemorrhage accompanied by severe head injury, resuscitation with HS may benefit victims by decreasing ICP and diminishing the effects of an intracranial mass.

Animals↗
PubMed1992

Prospective evaluation of preoperative fluid resuscitation in hypotensive patients with penetrating truncal injury: a preliminary report.

Although intravenous (IV) fluid therapy is routinely prescribed for hypotensive injury victims, there are concerns that elevating the blood pressure before hemorrhage is controlled may be detrimental. This is a preliminary report of an ongoing randomized study designed to evaluate the effect fluid resuscitation, delayed until surgical intervention, has on the outcome for hypotensive victims of penetrating truncal injury. In the first year, 300 consecutive patients with gunshot or stab wounds to the trunk who had a systolic blood pressure of 90 mm Hg or less were entered into the study. Patients were excluded from the outcome analysis because of death at the scene or minor injury not requiring surgical intervention. The remaining study patients were randomized into (1) an immediate resuscitation group (n = 96) for whom IV fluid resuscitation was initiated in the ambulance and in the emergency center before surgical intervention, or (2) a delayed resuscitation group (n = 81) for whom IV fluid resuscitation was delayed until the time of surgical intervention. The two study groups were found to be well balanced with respect to anatomic injury severity, pretreatment vital signs, survival probability, and preoperative treatment times. There were no significant differences in the rate of survival to hospital discharge (immediate resuscitation group, 56%; delayed resuscitation group, 69%). There were no significant differences in the rate of postoperative complications. Further study is necessary to determine if it is advantageous to delay fluid resuscitation until surgical intervention.

Abdominal Injuries↗
PubMed1994

A method to determine the adequacy of resuscitation using tissue oxygen monitoring.

The change in tissue PO2 in response to an increased inspired O2 challenge may be related to the state of cellular oxygenation, and hence the adequacy of resuscitation. To test this hypothesis, we measured tissue PO2 during inspired O2 challenges in 29 injured patients during acute resuscitation or intensive care unit monitoring. The O2 challenge test had 100% sensitivity and specificity in detecting flow-dependent O2 consumption in invasively monitored patients in the intensive care unit. During acute resuscitation, 60% of patients had negative initial O2 challenge test results, indicating that flow-dependent O2 consumption might have been present. Of nine such patients, five had subsequent positive O2 challenge test results after fluid resuscitation, indicating successful resuscitation. Four patients (27% of acute resuscitations), however, had repeatedly negative findings, possibly indicating persistent inadequate cellular oxygenation despite fluid resuscitation. Other commonly measured variables did not differentiate these patients. Monitoring of tissue PO2 during an inspired O2 challenge may be a useful test for determining the adequacy of resuscitation from hypovolemic shock.

Humans↗
PubMed1996

The use of oxygen consumption and delivery as endpoints for resuscitation in critically ill patients.

OBJECTIVE: Oxygen consumption (VO2I) and delivery (DO2I) indices have been stated to be superior to conventional parameters as endpoints for resuscitation. However, another interpretation of published data is that inability to increase VO2I/DO2I given adequate volume resuscitation reflects inadequate physiologic reserve and poor outcome. DESIGN: Fifty-eight critically ill patients were randomized to two groups. In group 1 (27 patients) attempts were made to maintain VO2I > or = 150 or DO2I > or = 600 mL/min/m2. If DO2I was > 600, no attempt was made to increase VO2I even if it was < 150. Group 2 (31 patients) was resuscitated based on conventional parameters. Volume resuscitation protocols and goals for pulmonary capillary wedge pressure were the same in both groups. VO2I/DO2I were recorded in group 2, but physicians were blinded to this data. Age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation (APACHE II) score were not different between groups. MAIN RESULTS: Three patients in group 1 and two patients in group 2 died of organ failure (OF). One additional patient in group 2 died of refractory shock within 24 hours. Two of the patients in group 1 who died failed to meet VO2I/DO2I goals within 24 hours despite maximal resuscitation. Mortality was not different between the groups even with exclusion of the group 1 patients who failed to meet VO2I/DO2I goals (p = 0.66). After exclusion of the patient in group 2 who died of refractory shock, OF occurred in 18 of 27 (67%) in group 1 and in 22 of 30 (73%) in group 2 (p = 0.58). Length of ventilator support, intensive care unit stay, and hospital stay were not different between groups. When all patients were assessed, no difference was found in the incidence of OF between patients who attained the VO2I goal and those who did not. OF occurred in 20 of 34 (59%) patients who maintained a mean DO2I > or = 600 during the first 24 hours of the study and in 21 of 24 (88%) of those who did not (p < 0.02). CONCLUSIONS: No difference was found in the incidence of OF or death in patients resuscitated based on oxygen transport parameters compared to conventional parameters. These data suggest that given adequate volume resuscitation, oxygen-based parameters are more useful as predictors of outcome than as endpoints for resuscitation.

APACHE↗
PubMed1997

Hypertonic saline resuscitation decreases susceptibility to sepsis after hemorrhagic shock.

BACKGROUND: We hypothesized that improvements in cellular immune function after hypertonic saline (HTS) resuscitation will alter the outcome of sepsis after hemorrhage. METHODS: To test this hypothesis, a two-hit model was used. Hemorrhage was induced in BALB/c mice by catheterizing the femoral artery and bleeding until a mean arterial pressure = 35 mm Hg was reached and maintained for 1 hour. Resuscitation was performed with HTS (NaCl 7.5%, 4 mL/kg) or lactated Ringer's (LR, twice the shed blood volume), plus the shed blood. Cecal ligation and puncture (CLP) was performed 24 hours after hemorrhage. Mortality was assessed for 72 hours, comparing HTS (n = 14) and LR (n = 13) resuscitation. Another set of animals (n = 10 in each group at each time point) were killed at 2 and 24 hours after blood collection. Liver and blood were cultured for the presence of bacteria, and lung and liver samples were scored on a scale from 0 (normal) to 4 (most severe) in a blind fashion by a pathologist. RESULTS: Mortality 72 hours after CLP was 14.3% in HTS and 76.9% in LR treated animals (p < 0.002). At 24 hours after CLP, 44% of HTS, but 77% of LR treated animals had > 1,000 colony forming units/mL of blood. Positive liver cultures (> 100,000 colony forming units/g) also showed the same trend (HTS = 30%, LR = 60%). Autopsies revealed a better containment of the infection (abscess formation) in the HTS group. At 2 hours, lung scores were 1.2 +/- 0.25 and 2.6 +/- 0.31 for HTS and LR, respectively (p < 0.002). At 24 hours, HTS treated animals showed marked improvement of lung injury, while the scores in the LR group remained high. A significant difference was also observed regarding liver injury. At 2 hours, scores were 0.4 +/- 0.22 and 2.3 +/- 0.16 for HTS and LR, respectively (p < 0.002). At 24 hours, HTS treated animals showed normal hepatic architecture, although mild injury was still observed in the LR group. CONCLUSION: HTS resuscitation leads to increased survival after hemorrhage and CLP. Marked improvements were observed in lung and liver injury compared with isotonic resuscitation. The better containment of the infection observed with HTS resuscitation corresponds to a marked decreased in bacteremia. HTS resuscitation stands as an alternative resuscitation regimen with immunomodulatory potential.

Animals↗
PubMed1997

The importance of the command-physician in trauma resuscitation.

OBJECTIVE: Definitive trauma team leadership, although difficult to measure, has been shown to improve trauma resuscitation performance. The purpose of this study was to evaluate the effect of an identified command-physician on resuscitation performance. In addition, the leadership capability of four physician combinations functioning as command-physician was studied. DESIGN: Retrospective review. METHODS: Videotapes of trauma resuscitations performed at a Level I trauma center over a 25-month period were reviewed. The presence of an identified command-physician was determined by multidisciplinary consensus. Resuscitation performance was measured by compliance with three objective criteria: primary survey, secondary survey, and definitive plan; and two subjective criteria: orderliness, and adherence to Advanced Trauma Life Support protocol. Performance was then analyzed (1) as a function of the presence or absence of a command-physician, and (2) between four identified physician combinations: AF (attending surgeon + trauma fellow); F (trauma fellow); ASR (attending surgeon + senior surgical resident); SR (senior surgical resident). Chi square and the Mann-Whitney U tests were applied. RESULTS: A total of 425 trauma resuscitations were reviewed. A command-physician was identified (CP[Pos]) in 365 resuscitations (85.7%); no command-physician was identified (CP[NEG]) in 60 (14.3%). Compliance with completion of secondary survey (81.4%) and formulation of a definitive plan (89.6%) was significantly higher in the CP(POS) group. Subjective scores for orderliness and adherence to Advanced Trauma Life Support protocol were significantly higher in the CP(POS) group. In the CP(POS) resuscitations, formulation of a definitive plan was lower in SR when compared with the other three physician combinations. CONCLUSIONS: An identified command-physician enhances trauma resuscitation performance. Completion of the primary and secondary survey is not affected by the physician combination. Prompt formulation of a definitive plan is facilitated by the active involvement of an attending traumatologist or a properly mentored trauma fellow.

Evaluation Studies as Topic↗
PubMed2000

Intrathoracic blood volume as an end point in resuscitation of the severely burned: an observational study of 24 patients.

BACKGROUND: Treatment of burn shock according to empirical resuscitation formulas is still considered the gold standard, and the burn community does not advocate the use of invasive cardiorespiratory monitoring in general. As a consequence, data dealing with early postburn hemodynamics are sparse, and only few studies have paid attention to the topic of end-point burn shock resuscitation. However, recent studies have suggested that burn survival may be improved when invasive monitoring is used to guide fluid therapy during the shock phase. MATERIALS AND METHODS: In an observational study of 24 patients with severe burns, the transpulmonary double indicator dilution technique was used for semi-invasive hemodynamic monitoring. The clinical utility of the intrathoracic blood volume (ITBV) as an end-point variable for fluid resuscitation was evaluated, comparing correlation of filling pressure obtained by a pulmonary artery catheter and intrathoracic blood volume to cardiac index and oxygen delivery. In addition fluid volume predicted by the Parkland burn formula was compared with the actual fluid volume given when ITBV was used as end point for resuscitation. RESULTS: ITBV-guided resuscitation was associated with restoration of preload and peripheral delivery of oxygen within 24 hours in the majority of patients. Augmentation of ITBV was significantly correlated with changes in cardiac index and oxygen transport rate. No such correlation could be demonstrated for the conventional preload parameters such as central venous pressure and pulmonary capillary wedge pressure. Thus, ITBV seemed in burned, hypovolemic patients a better indicator of the preload component of the cardiac output than the conventional preload parameters obtained with the pulmonary artery catheter. Significantly larger volumes of crystalloids than predicted by the Parkland formula were administered when ITBV was used as end point for resuscitation. The extravascular lung water remained normal during this extraordinary high volume load. CONCLUSION: ITBV may be a reliable preload indicator to guide volume therapy in life-threatening burns, and end-point-fixed resuscitation to this parameter seems to be associated with significantly higher fluid administration than calculated compared with traditional burn formulas. The effects of burn resuscitation to fixed end points on survival and multiple organ failure should be evaluated in future randomly assigned trials.

Acute Disease↗
PubMed2000

Assessing pediatric senior residents' training in resuscitation: fund of knowledge, technical skills, and perception of confidence.

OBJECTIVE: To describe pediatric housestaff knowledge, experience, confidence in pediatric resuscitations and their ability to perform important resuscitation procedures during the usual training experience. DESIGN AND PARTICIPANTS: Cohort study of PGY-3 level residents in a ACGME accredited pediatric residency training program at a large, tertiary care children's hospital. METHODS: Fund of knowledge was assessed by administering the standardized test from the Pediatric Advanced Life Support (PALS) Course in addition to a supplemental short answer test requiring clinical problem-solving skills. Procedural skills were evaluated through observation of the resident performing four procedures during a skills workshop using a weighted step-wise grading sheet. Resident experience and confidence was quantified using an anonymous survey. RESULTS: Ninety-seven percent of residents participated. Residents achieved high scores on the standardized PALS test (93.2%+/-5.5), but performed less well when answering more complicated questions (60.0%+/-9.9) on the short answer test. No resident was able to successfully perform both basic and advanced airway skills, and only 11% successfully completed both vascular skills. Although residents were overall confident in their resuscitation skills, performance in the skill workshop revealed significant deficits. For example, only 18% performed ancillary airway maneuvers properly. None of the residents performed all four skills correctly. Experience in both real and mock resuscitations was infrequent. Residents reported receiving feedback on their performance less than half of the time. Over 89% of them felt that resuscitation knowledge and skill were important for their future chosen career. CONCLUSION: Pediatric residents infrequently lead or participate in real or mock resuscitations. Although confident in performing many of the necessary resuscitation skills, few residents performed critical components of these skills correctly. Current pediatric residency training may not provide sufficient experience to develop adequate skills, fund of knowledge, or confidence needed for resuscitation.

Attitude of Health Personnel↗
PubMed2002

Deferoxamine and hespan complex as a resuscitative adjuvant in hemorrhagic shock rat model.

The optimal type and amount of fluid for resuscitation of injured patients in hemorrhagic hypovolemic shock remains controversial. Use of deferoxamine, an iron chelator and oxygen-free radical scavenger, and hespan (hydroxyethyl starch), a colloid plasma expander, was evaluated in a rat hemorrhagic shock model. Eighty Sprague-Dawley male rats were utilized in four experiments. In these rats, bi-femoral cutdowns were performed for blood withdrawal, resuscitation, blood sampling, and continuous blood pressure monitoring. All rats, except control (with bilateral cutdown only), were bled and maintained at 40 mmHg for 90 min. The shed blood was returned and animals were resuscitated. One hour later, 2 mg/kg lidocaine was injected and blood samples were taken at 10, 15, 30, and 60 min for evaluation of lidocaine derivative monoethylglycinexylidide (MEGX) by fluorescent polarization immunoassay. In experiment 1 (n = 31), resuscitation with different volumes of Ringer's lactate (7.5 mL, 15.0 mL, and 30.0 mL/kg) was compared and 7.5 mL/kg LR was most beneficial. In experiment 2 (n = 22), resuscitation with three doses of Hespan (3.75 mL, 7.5 mL, and 15 mL/kg) was compared. A dose of 15 mL/kg significantly improved the liver function. In experiment 3 (n = 15), resuscitations with two doses of deferoxamine (30 mg and 100 mg/kg) were compared. A dose of 100 mg/kg significantly improved the liver function. In experiment 4 (n = 12), a combination of deferoxamine (100 mg/kg) and Hespan (3.75 and 7.5 mL) was used. Deferoxamine (100 mg/kg) complexed with 7.5 mL of Hespan was found the most beneficial resuscitation. This conjugate could be a choice as a resuscitative adjuvant in hypovolemic shock without any side effects.

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