Shock blood and fluid resuscitation
Because CVP may be unreliable in assessing volume status or left ventricular function, pulmonary artery catheterization may be considered for diagnosis or for more precise titration of fluid therapy if there is no cardiovascular improvement after initial therapy.
There is also a concern that the study populations were relatively young and that elderly patients may not be able to tolerate fast and high volume fluid resuscitation as well as younger patients.
For these reasons, the evidence was downgraded for indirectness. The recommendation for the use of crystalloids for fluid resuscitation was based on moderate quality clinical evidence and the evidence for cost-effectiveness of crystalloids.
No studies of early vs. In controlled hemorrhagic shock CHS where the source of bleeding has been occluded fluid replacement is aimed toward normalization of hemodynamic parameters.
High vs. Precious time is not wasted by introducing an intravenous line before evacuation, but infusion can be started en route to the medical facility.
Fluid resuscitation in shock
When evacuation time is expected to be longer than one hour, an intravenous line is introduced and fluid resuscitation is started before evacuation. Electrolyte and metabolic disorders as well as coagulation deficiencies should be corrected. In Wiggers developed an animal model of graded controlled hemorrhagic shock by uptake of shed blood into a reservoir to maintain a predetermined level of hypotension [ 4 ]. Gelatin is more costly than crystalloids and there was no evidence of a clinical benefit with its use over crystalloids and therefore its cost-effectiveness is unproven — see research recommendation. Choices in fluid type and volume during resuscitation: Impact on patient outcomes. However, this compensation is overwhelmed after major losses. Mild to moderate hypotension allows for clot formation and slows bleeding from injured blood vessels hypotensive resuscitation. Aggressive fluid resuscitation during the Vietnam War with red blood cells, plasma, and crystalloid solutions allowed patients who previously would have succumbed to hemorrhagic shock to survive. Additional studies by this group demonstrated that this prolonged period of hemorrhagic hypotension was associated with the development of microvascular injury with marked ECF deficit which could be corrected only by the administration of isotonic crystalloids in volumes 2 to 3 times the estimated blood loss to achieve survival. An exception is a patient with cardiogenic shock who typically does not require large volume infusion. This was the basis of the current well known dogma "3 to 1 rule" for the treatment of hemorrhagic shock, which was adopted by the ATLS for the treatment of trauma casualties [ 6 ]. N Engl J Med 20 : , According to the guidelines of the Israeli Defense Forces IDF fluid resuscitation of CHS is aimed toward normalization of hemodynamic parameters, in contrast to UCHS where the principles of hypotensive resuscitation are operative and treatment is started when one of the three parameters is documented [ 18 ]: a.
Other than that pertaining to the use of albumin and tetrastarches for fluid resuscitation, much of the evidence in the reviews presented in this chapter on the best type of fluid to use and the optimal volume, timing and rate of its administration was of low or very low quality, with major limitations in the design of studies which increase the risk of bias.
Precious time is not wasted by introducing an intravenous line.
Hypovolemic shock treatment guidelines
In controlled hemorrhagic shock CHS where the source of bleeding has been occluded fluid replacement is aimed toward normalization of hemodynamic parameters. Claude Bernard suggested that the organism attempts to maintain constancy of its milieu interie despite external forces that attempt to disrupt it [ 1 ]. Because of the rapid equilibration of balanced salt solutions into the extracellular space, larger volumes may be required for adequate resuscitation, resulting in decreased intravascular oncotic pressure. When the CVP is within the normal range, volume depletion cannot be excluded, and the response to to mL fluid boluses should be assessed; a modest increase in CVP in response to fluid generally indicates hypovolemia. Additional studies by this group demonstrated that this prolonged period of hemorrhagic hypotension was associated with the development of microvascular injury with marked ECF deficit which could be corrected only by the administration of isotonic crystalloids in volumes 2 to 3 times the estimated blood loss to achieve survival. Several colloid solutions were studied in clinical practice including human albumin, hydroxyl ethyl starch HES , and dextran. The evidence was low quality for all cause mortality and of very low quality for morbidity. They were also interested in the volumes of fluid infused for studies comparing different fluid types for resuscitation, as success with fluid resuscitation achieved with a lower volume, implies that the fluid used might have better intravascular expanding properties. The recommendation of the use of human albumin solution for fluid resuscitation of patients with sepsis is based on the evidence from the reviews presented including the economic analysis which supported its use. Hemoglobin-based oxygen carriers are notable for high oxygen carrying capacity, an appreciable oncotic effect, and prolonged shelf life. Fluid resuscitation in CHS is aimed toward normalization of hemodynamic parameters, in contrast to UCHS, where hemostasis cannot be safely achieved, and early rapid evacuation to a surgical facility is considered the most important step of management after the airway and breathing have been secured. Choices in fluid type and volume during resuscitation: Impact on patient outcomes. The recommendation for notusing tetrastarch for fluid resuscitation was based on the evidence of an increase in mortality in the long term mortality at 90 days. Precious time is not wasted by introducing an intravenous line.
based on 12 review