The Role of Sodium-Containing Solutions in the Treatment of Oligemic Shock

Comparison of whole blood versus red blood cells and plasma to correct trauma-induced coagulopathy ex vivo

BACKGROUND

Early resuscitation is based on platelet-poor components such as red blood cells and plasma (RBC + P), contributing to platelet dilution and worsening of trauma-induced coagulopathy (TIC). We aimed to compare the ability of cold-stored whole blood (WB) versus RBC + P as a single component to correct TIC.

STUDY DESIGN AND METHODS

Blood samples were collected on admission from trauma patients who required activation of the major hemorrhage protocol at a single UK major trauma center in 2021/2022. Samples were spiked ex vivo with volumes equivalent to two, four, or eight units of WB or RBC + P stored for a maximum of 2 weeks. Thromboelastometry, platelet counting, and multiple electrode aggregometry (MEA) were performed.

RESULTS

Samples from 20 adult trauma patients were analyzed. Median age was 32 years (27-42), 89% were male, 70% had platelet dysfunction (tissue factor-activated ROTEM [EXTEM]-tissue factor-activated ROTEM with cytochalasin D [FIBTEM] clot amplitude at 5 min [A5] ≤ 30 mm), 65% were coagulopathic (EXTEM A5 ≤ 40 mm), and 42% died. EXTEM-FIBTEM A5 was higher following spiking with WB than RBC + P (33 mm, 26-33, vs. 27 mm, 24-30, p < .001). WB-spiking corrected platelet dysfunction in 2 patient samples out of 20, whereas RBC + P increased the frequency of platelet dysfunction (1/20 sample) and TIC (4/20 samples). RBC + P was associated with a dose-dependent deterioration in rotational thromboelastometry (ROTEM) clot strength and dynamics, platelet count, and aggregation in response to multiple agonists compared with WB-spiking, which maintained or partially corrected these abnormalities.

CONCLUSION

Compared with RBC + P, WB better preserves ex vivo platelet-related ROTEM parameters, platelet count, and aggregation, but does not fully correct these common derangements of TIC.

Postinjury abdominal compartment syndrome: from recognition to prevention

Postinjury abdominal compartment syndrome (ACS) is an example of a deadly clinical occurrence that was eliminated by strategic research and focused preventions. In the 1990s, the syndrome emerged with the widespread use of damage control surgery and aggressive crystalloid-based resuscitation. Patients who previously exsanguinated on the operating table made it to intensive care units, but then developed highly lethal hyperacute respiratory, renal, and cardiac failure due to increased abdominal pressure. Among many factors, delayed haemorrhage control and preload driven excessive use of crystalloid resuscitation were identified as modifiable predictors. The surrogate effect of preventive strategies, including the challenge of the 40-year-old standard of large volume crystalloid resuscitation for traumatic shock, greatly reduced cases of ACS. The discoveries were rapidly translated to civilian and military trauma surgical practices and fundamentally changed the way trauma patients are resuscitated today with substantially improved outcomes.

Fluid and electrolyte management in the pediatric surgical patient

The following is a quick guide to the perioperative fluid program discussed 1. Always assess the state of fluid repletion in any patient presenting for surgical management (Note: This does not necessarily mean operative management). 2. If the patient is hypovolemic or if there is the possibility of hypovolemia and you are uncertain, restore volumes equal to 25% of the patient's blood volume with a fluid push made up of an osmotically active electrolyte solution modified for the additional requirements of red cell carrying capacity or clotting factors. If this results in a urine output and correction of hypoperfusion or hypotension, maintain an increased fluid administration program until a stable urine output and good perfusion are achieved. If the patient is normovolemic at the time of presentation, particularly if the patient is having an elective operative procedure and does not have an intravenous line in place, calculate the insensible losses that will occur during the time of fluid restriction before surgery and correct at least 50% of these during the operative procedure. 3. Develop the postoperative fluid program as a combination of 24-hour insensible loss replacement (maintenance fluid), restoration of measured losses, and an estimate (guess) as to the volume requirements for third-space fluid shifts. Restore blood losses if appropriate or administer additional volumes of balanced electrolyte solution at a 3-to-1 ratio to replace measured blood loss. 4. Total the insensible loss measurement, the measured losses, and the estimate of third-space requirement and divide this volume by 24 to get an initial hourly fluid administration rate. 5. Select the most osmotically active fluid that you intend to use and administer it first at the calculated rate. Carefully monitor the patient's urine output. 6. Increase or decrease the fluid administration rate to bring the hourly urine output within the guidelines for the appropriate hourly urine output (milliliters) for the particular patient based on size (kilograms). 7. When the urine output falls within the appropriate range, maintain that rate of fluid administration, and recalculate the volumes required because of insensible loss, measured loss, and third-space shifts by subtracting the amount of fluid already administered from the volume that will be required in the remainder of the 24 hours; this will yield the volumes of additional maintenance, measured loss, and third-space fluids that will make up the remainder of the fluids needed for the 24 hours.(ABSTRACT TRUNCATED AT 400 WORDS)