Page 34 - Journal of Special Operations Medicine - Fall 2014

A prospective, randomized, controlled double-blind, Beecher remarked in World War II that glucose and sa-
multicenter trial with 100 patients compared Voluven to line solutions were useful only in the treatment of de-
22
hetastarch (HES 670/0.75 in saline) for volume replace- hydration. Kwan noted in 2009: “Every year, tens of
ment during major orthopedic surgery and found that thousands of patients receive intravenous fluids for the
they were equally efficacious for this purpose. Voluven, management of bleeding. The Advanced Trauma Life
however, had less effect on coagulation as measured by Support (ATLS) protocol of the American College of
the nadir of factor VII and von Willebrand factor dur- Surgeons recommends the liberal use of isotonic crystal-
144
ing the 2 hours post surgery. It is important to note loid to correct hypotension in bleeding trauma patients.
that this study used Voluven and HES in saline (Hespan) Nevertheless, we could find no reliable evidence to sup-
149
rather than Hextend. port or to not support this recommendation.” When
crystalloids are used to replace blood loss, it is typical to
Albumin infuse three times the volume of shed blood in order to
Albumin is a colloid derived from human plasma that replace the intravascular volume. 43,134,150 Animal studies
has been used to resuscitate individuals in hemorrhagic have shown that crystalloid options designed to mitigate
and other types of shock. In a post-hoc analysis of 460 lactic acidosis have improved survival in hemorrhagic
patients with TBI in the Saline versus Albumin Fluid Re- shock. 151
suscitation (SAFE) study performed at 24 months after
randomization, patients who had received albumin were Crystalloid-based resuscitation, but not blood products,
found to have a higher mortality than those who had is associated with increased risk of developing moderate-
53
received saline (33.2% versus 20.4%). Among patients to-severe hypoxemia in trauma patients. The authors
with severe brain injury, the increase in mortality was of this study note that the negative effects of crystalloids
145
even larger (41.8% versus 22.2%). This finding has in resuscitating trauma patients in hemorrhagic shock
resulted in the recommendation that albumin not be are becoming better understood. Another study states
administered to trauma patients with TBI. 146,147 This re- that: “. . . the disadvantages of crystalloids such as sa-
striction effectively precludes its use by combat medical line and lactated Ringer’s solution for the management
personnel, since many of the casualties that they treat on of hemorrhagic shock are well known.” Current DCR
56
the battlefield will have a combination of hemorrhagic strategies include minimizing crystalloid for the resusci-
shock and TBI. Several Cochrane reviews of albumin tation of patients with hemorrhagic shock to avoid po-
use for volume expansion in critically ill hypovolemic tentiating the coagulopathy of trauma. 49,52,75
patients also noted that albumin did not confer a sur-
vival advantage over less expensive alternatives such as Crystalloids—Lactated Ringer's
saline. 130,148 If blood products and Hextend are not available and
a crystalloid fluid must be used, LR is preferred over
Crystalloids—General NS because it does not produce the hyperchloremic
Crystalloids are electrolyte solutions whose main osmoti- acidosis that NS does. 152 In an animal model of con-
cally active particle is sodium. Sodium distributes through- trolled hemorrhage comparing LR, NS, Plasma-Lyte A,
out the extracellular fluid space. Since 75% to 80% of the and Plasma-Lyte R, LR produced the highest 2-hour
extracellular fluid space is composed of interstitial fluid, survival rate and was recommended by the authors
that proportion of infused crystalloid is distributed into as the best choice as a resuscitation fluid among the
150
the interstitial space rather than remaining intravascular four crystalloids studied. Waters et al. found that us-
space. Crystalloids, therefore, have the predominant ef- ing LR for fluid replacement during abdominal aortic
fect of expanding the interstitial space as opposed to the aneurysm repair produced less acidosis and less intra-
intravascular space. An infused volume of 1L of 0.9% operative blood loss than NS but with no decrease in
127
sodium chloride adds 275mL to the plasma volume and mortality. 153
825mL to the interstitial volume after equilibration. The
total of these two volumes (1100mL) exceeds the infused Moore notes that the lack of a proven survival benefit
volume because NS is slightly hypertonic and causes a from initial resuscitation with colloids as opposed to
small shift of fluid from the intracellular to the extracel- crystalloids, and the reduced expense of fluids like LR
lular space. Diffusion of crystalloids into the extravas- ($3 for 500mL of volume expansion) compared with
127
cular space may result in complications of resuscitation albumin ($88 for albumin 5%) and Hextend ($17) ar-
such as ARDS and hypo xemia, 12,19,81 as well as abdomi- gues in favor of using crystalloids like LR in US trauma
nal compartment syn drome. 28,53,133 A recent study of 799 centers. A similar rationale was used by the IDF in
154
patients who underwent trauma laparotomies found that deciding to use LR in their fluid resuscitation protocol,
reducing the volume of infused crystalloid reduced the in- noting that their evacuation times are short and the cost
28
cidence of ACS from 7.4% to 0% (p = .001). difference was not justified.
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26 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014