J Trauma
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The systemic inflammation that occurs in shock states is believed to promote overexuberant microcirculatory activation, the release of toxic proteases and oxygen radicals causing microvascular damage, and subsequent tissue and organ injury. Although shock-associated microvascular failure is often unresolved after standard resuscitation, hypertonic saline (HTS) appears to reduce microvascular collapse, restoring vital nutritional blood flow. ⋯ Furthermore, fewer cellular interactions have been correlated with attenuation in microvascular wall permeability after resuscitation with HTS. Better characterization of microcirculatory effects by hypertonic saline may provide mechanisms for improved morbidity and mortality associated with hypertonic resuscitation.
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A number of oxygen therapeutics have completed safety trials and are now undergoing efficacy evaluation in multicenter phase III trials in North America and Europe. There are numerous potential advantages of these solutions when compared with packed red blood cells. ⋯ A few problems remain, including short biologic half-life, which may limit the application to times when the patient is most acutely anemic (i.e., in the intraoperative or immediate perioperative phase) or for emergent use. Nevertheless, a safe, effective alternative therapy providing oxygen delivery characteristics comparable to red blood cells may soon be available that could have significant impact on the way that we resuscitate trauma patients.
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Burn injury remains a constant source of morbidity and mortality in the military environment. The logistic constraints of combat casualty care can make it impossible to provide the large volumes of crystalloid typically used for burn resuscitation. Unlike penetrating trauma, the immediate and sustained fluid requirements necessary for resuscitation of thermal injury preclude the use of limited or hypotensive resuscitation. ⋯ Although strategies such as early use of colloids or hypertonic saline may not reduce morbidity or mortality when compared with large-volume infusions of lactated Ringer's, they can be volume sparing for some hours and sustain life until more definitive therapy is initiated. An intriguing hypothesis is that oral resuscitation can effectively restore plasma volume after thermal injury. We present data from recent experiments of gastric and intestinal infusions of an oral rehydration solution in a porcine burn model that demonstrates restoration of plasma volumes and improvement in hemodynamic parameters associated with significant gastric emptying and intestinal absorption.
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Meta Analysis
Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis.
Immunosuppression is a consequence of allogeneic (homologous) blood transfusion (ABT) in humans and is associated with an increased risk in cancer recurrence rates after potentially curative surgery as well as an increase in the frequency of postoperative bacterial infections. Although a meta-analysis has been reported demonstrating the relationship between ABT and colon cancer recurrence, no meta-analysis has been reported demonstrating the relationship of ABT to postoperative bacterial infection. ⋯ These results demonstrate that ABT is an associated and apparently significant and frequently overlooked risk factor for the development of postoperative bacterial infection in the surgical patient. Allogeneic blood transfusion is a greater risk factor in the traumatically injured patient when compared with the elective surgical patient for the development of postoperative bacterial infection.
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Coagulopathy resulting from hydroxyethyl starch (HES) administration is well documented for high-molecular-weight, highly substituted HES solutions. These are the only starch-based synthetic colloids approved for volume replacement in the United States. Recent developments in European colloid solutions revolve around designing new starch molecules. ⋯ This solution is without significant influence on coagulation. Actual experimental work is concentrating on modulating the inflammatory response of monocytes and endothelial cells after infusion of colloid solutions. This may help prevent or even correct capillary leak, and the intravascular persistence of infused colloidal might be prolonged.