Resuscitation
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Randomized Controlled Trial Comparative Study Clinical Trial
Advantages of dextran 70 over Ringer acetate solution in shock treatment and in prevention of adult respiratory distress syndrome. A randomized study in man after traumatic-haemorrhagic shock.
Twenty-three patients aged 20-58 years in a serious state of shock and suffering from major pelvic and femoral fractures sustained in traffic accidents were studied. As initial fluid management, either dextran 70 (1000-1500 ml) together with Ringer's acetate solution (2000-3000 ml), or Ringer's acetate alone (5000-8000 ml), was administered on a random basis. Thus, 12 patients received dextran and 11 patients crystalloid treatment to counteract shock. ⋯ To maintain a stable circulation and a urinary output above 50 ml/h the Ringer patients required significantly more (P less than 0.001) crystalloid solution (910 +/- 300 ml) daily than the dextran patients (460 +/- 400 ml). The frequency of adult respiratory distress syndrome (ARDS) was significantly lower (P less than 0.05) in the dextran group (0 of 12) than in the Ringer group (4 of 11). Thus, in the initial treatment of traumatic-haemorrhagic shock and in the post-resuscitative period dextran 70 would seem of advantage over Ringer's acetate both in shortening the shock period and in reducing the frequency of adult respiratory distress syndrome.
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The authors analyse the incidence of puncture, catheterization and failures of positioning in a series of 420 central venous catheterizations performed in 388 patients, using six transcutaneous approaches: supraclavicular and infraclavicular subclavian, external and internal transjugular, antecubital and brachiocephalic. Puncture failures were recorded at 7.9% per 36 failures from 456 attempts, catheterization failures at 5.8% per 26 failures from 446 attempts, and misplacements at a rate of 5.7% per 23 misplacements during 420 catheterizations. ⋯ A high rate of failures and misplacements was recorded in the antecubital and external jugular groups. The antecubital veins, however, should be reserved for orthopnoeic sitting patients, the success rate being significantly increased if the patients are sitting.
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The authors have analysed the incidence of specific complications in a series of 420 intracaval catheters placed in 388 patients, using six transcutaneous puncture techniques: supraclavicular and infraclavicular subclavian, external and internal jugular, antecubital and brachiocephalic approaches. Strict and moderate criteria were used to evaluate the frequency of complications. Using strict criteria, the lowest rate of surgical complications (5%) was found with the antecubital and external jugular approach, followed by infraclavicular (6.7%) and supraclavicular (9.3%) subclavian techniques; the highest rate was seen with internal jugular (10%) and brachiocephalic (15%) routes. ⋯ Manifest thromboembolic complications were observed only in the brachiocephalic and antecubital groups (2.5% and 10%, respectively), the overall incidence of pulmonary embolism being 0.2%. None of the approaches used can be recommended as an exclusive method of choice. The risks of central venous catheterization should be minimalized by adherence to strict principles of placing as well as care of the indwelling intravenous catheters.