Elsevier

The Lancet

Volume 363, Issue 9425, 12 June 2004, Pages 1988-1996
The Lancet

Series
The next generation in shock resuscitation

https://doi.org/10.1016/S0140-6736(04)16415-5Get rights and content

Summary

Resuscitation of the severely injured patient who presents in shock has improved greatly, following focused wartime experience and insight from laboratory and clinical studies. Further benefit is probable from technologies that are being brought into clinical use, especially hypertonic saline dextran, haemoglobin-based oxygen carriers, less invasive early monitors, and medical informatics. These technologies could improve the potential of prehospital and early hospital care to pre-empt or more rapidly reverse hypoxaemia, hypovolaemia, and onset of shock. Damage control surgery and definitive interventional radiology will probably combine with more real-time detection and intervention for hypothermia, coagulopathy, and acidosis, to avoid extreme pathophysiology and the “bloody vicious cycle”. Although now widely practised as standard of care in the USA and Europe, shock resuscitation strategies involving haemoglobin replacement and fluid volume loading to regain tissue perfusion and oxygenation vary between trauma centres. One of the difficulties is the scarcity of published evidence for or against seemingly basic intervention strategies, such as early or large-volume fluid loading. Standardised protocols for resuscitation, representing the best and most current knowledge of the clinical process, could be devised and widely implemented as interactive computerised applications among trauma centres in the USA and Europe. Prevention of injury is preferable and feasible, but early care of the severely injured patient and modulation of exaggerated systemic inflammatory response due to transfusion and other complications of traditional strategies will probably provide the next generation of improvements in shock resuscitation.

Section snippets

Crystalloid versus colloid debate

Since the early 1940s, when restoration of circulatory blood volume was embraced as pivotal in shock resuscitation, controversy has existed as to which fluid to use for this purpose.11 A review article from that era concluded that saline and glucose solutions were unsuitable because they were quickly lost from the intravascular space. Plasma and serum were considered the best substitutes for whole blood—and in some cases, better than blood itself.12 This was the resuscitation strategy used in

Why change resuscitation?

Over the last decade, epidemiological studies of patients with torso trauma have revealed several disturbing observations that have led us to conclude that fundamental changes in current resuscitation strategies are needed. Although now widely practised as standard of care in the US and Europe, shock resuscitation strategies involving haemoglobin replacement and fluid volume loading to regain tissue perfusion and oxygenation are quite variable among trauma centres, and published evidence for or

Crystalloid versus colloid debate revisited

Unfortunately, the prospective randomised controlled trials comparing crystalloid and colloid resuscitation were done in the 1970s and 1980s, before the recognition of abdominal compartment syndrome as an important clinical entity. Additionally, albumin was the principal colloid used, but other types of colloid (starches and gelatins) are available. Because of their higher molecular weights, these colloids are confined to the intravascular space and their infusion results in more efficient

Blood substitutes

Another potential avenue to decrease the need for massive crystalloid administration could be earlier administration of blood—specifically, packed red blood cells. For reasons described earlier, the Advanced Trauma Life Support guidelines' recommendation to initiate resuscitation of class IV haemorrhagic shock with lactated Ringer's may not be optimal. However, the present limited supply of stored blood and potential adverse effects make the option of earlier administration of packed red blood

Haemorrhage control

The combination of hypothermia, coagulopathy, and acidosis is a syndrome that accelerates its effects in a cycle that is rapidly fatal unless interrupted.109 In addition to rewarming, coagulation factor replacement or enhanced haemostasis via intravenous infusion of procoagulants or antifibrinolytics might have a role in recalcitrant coagulopathy. Recombinant activated factor VII (rFVIIa) is an attractive candidate. When administered, it ostensibly binds only to exposed subendothelial tissue

Informatics and monitoring technology

Over the past decade, damage-control surgical techniques, presumptive embolisation by interventional radiology, and refined ICU resuscitation have saved many lives. To further improve outcome, future efforts need to be directed at better control of pre-ICU resuscitation. The first challenge will be to accurately identify high-risk bleeding patients in the field so that their early resuscitation can be optimised and novel treatments tested. Since the early 1970s, there has been a great interest

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