Page 33 - Journal of Special Operations Medicine - Fall 2014

warning noted an increased risk in mortality and renal setting is prohibited by Florida law. There were 281
replacement therapy associated with the use of these blunt trauma patients and 209 patients with penetrat-
136
products as used to treat critically ill patients. This ing trauma. Patients received standard of care fluids as
communication did not mention the use of these products determined by the attending physician. Hextend was
in the prehospital resuscitation of trauma patients, nor available on the formulary and used at the discretion
did it address the known increase in mortality and fluid of the responsible physician. The TCCC-recommended
overload complications resulting from the alternative use volume of Hextend (500mL initial volume followed
of large volume crystalloids in such patients. 6,25,28,53,61,81 by a second 500mL if clinically indicated) was used.
The study did not examine subgroups with controlled
Hextend (HES 670/0.75 in a and uncontrolled hemorrhage. While the study design
balanced electrolyte solution) limited its ability to determine a treatment benefit from
Hextend is the current CoTCCC-recommended resus- Hextend use, the authors noted that there was no evi-
citation fluid when blood products are not available. dence of coagulopathy or renal injury when using the
Hextend remains in the intravascular space for a much TCCC-recommended volume of Hextend. In a discus-
132
longer period of time than do crystalloid solutions, thus sion of these findings, Ogilvie noted that “. . . there is
providing a more sustained resuscitation with less vol- little doubt that Hextend did not promote coagulopathy
ume of fluid and reducing the iatrogenic resuscitation when used for initial resuscitation, especially after pen-
injury caused by crystalloid-related edema. A study of etrating trauma. 139
patients requiring volume replacement during major
surgery showed that Hextend (at an average dose of The Martini et al. study discussed previously docu-
1596mL) was as effective as 6% HES (670/0.7) in saline mented 100% survival 6 hours after an otherwise lethal
(Hespan) and resulted in less blood loss during surgery. 60% controlled hemorrhage model using volume-for-
In contrast to Hespan, Hextend did not significantly volume replacement of the blood lost with Hextend, but
prolong the time to onset of clot formation (based on the volume-for-volume resuscitation strategy used did
thromboelastography). 137 result in a dilutional coagulopathy. 43

No prospective trials in either the civilian or military Voluven (HES 130/0.4 in NS)
sectors have studied the outcomes from hypotensive re- Voluven is another synthetic HES solution that has a
suscitation with Hextend compared with other fluid re- lower molecular weight and a smaller number of hy-
suscitation strategies. However, a US DoD performance droxyethyl groups per molecule than Hextend. A study
improvement project studied the impact of prehospital from South Africa compared Voluven to NS in a ran-
fluid administration on outcomes in 530 combat casual- domized, controlled, double-blinded study of 115 se-
ties from Afghanistan in 2011 and 2012. Approximately verely injured patients who received more than 3L of
two-thirds of the casualties had injuries sustained from resuscitation fluid. No difference in mortality was
blasts. The mean 2005 ISS was 22.4 for casualties who found, but penetrating injury patients treated with
received Hextend (n = 65) and 17.9 for those who did Voluven were found to have less renal injury and better
not (n = 465.) Using the Shock Index (heart rate/SBP), lactate clearance than those treated with NS. No dif-
58.5% of Hextend patients were considered unstable (SI ferences were seen in patients who had sustained blunt
<0.5 or >0.9), while only 40% of non-Hextend patients trauma. Note that both fluids were given after arrival at
were considered unstable. Although there was no statis- the hospital. 140
tically significant difference in mortality, a trend toward
decreased mortality in the Hextend group was observed Myburgh et al.’s study examining the use of Voluven
(1.5% versus 4.9%), despite the higher ISS and higher compared with NS in intensive care unit patients found
SI in the Hextend group. There were also no statistically no clinical benefit to Voluven and that Voluven patients
significant differences in ARDS, increased intracranial had an increased rate of adverse events, including pru-
pressure (ICP), compartment syndromes, mean creati- ritus, skin rash, and renal replacement therapy. Most
141
nine values, or need for dialysis prior to discharge from of the patients in this study were sepsis rather than hem-
the Level V medical treatment facility. 138 orrhagic shock patients. A study on the use of Voluven
to replace blood lost during major surgery found that
The Hextend study by Ryan and colleagues performed Voluven reduced clot strength and increased periopera-
at Ryder Trauma Center in Miami looked at all adults tive hemorrhage. In contrast, a review on the use of
142
admitted during the study period who needed emer- HES solutions for volume replacement during surgery
gency surgery. This was a retrospective, nonrandom- concluded that there were no indications that the use of
ized study, since the community consent necessary to tetrastarches (such as Voluven) results in adverse renal
143
perform a randomized controlled trial in a prehospital effects or increased blood loss during surgery.

Fluid Resuscitation for Hemorrhagic Shock in TCCC 25