Hypotensive resuscitation (Hypo) has been considered an alternate resuscitation strategy in clinical settings that prevent the application of standard Advanced Trauma Life Support care. However, validation of this approach when used for prolonged periods of time remains to be demonstrated. The purpose of this study was to evaluate prolonged Hypo as an alternative to standard resuscitation using various currently available resuscitative fluids. Unanesthetized, male Sprague-Dawley rats underwent computer-controlled hemorrhagic shock and resuscitation. There were six experimental groups; nonhemorrhage (NH), nonresuscitated control (C), Hypo with lactated Ringer's (HypoLR), Hypo with Hextend, 6% hydroxyethyl starch in a balanced salt solution (HEX), Hypo with PolyHeme, a polymerized hemoglobin solution (HBOC), or standard resuscitation with LR (StandLR). Animals were bled over 15 min to a mean arterial blood pressure (MAP) of 40 mmHg where the blood pressure (BP) was held for 30 min. Hypo groups were resuscitated to 60 mmHg for 4 h followed by further resuscitation to 80 mmHg. StandLR rats were resuscitated to 80 mmHg immediately after the hemorrhage period. Animals were monitored until death or they were sacrifice at 24 h. Prolonged Hypo with HEX or LR resulted in a trend toward improved 24-h survival compared with C (71%, 65%, and 48%, respectively), and performed at least as well as StandLR (58% survival). HEX required significantly less intravenous fluid (0.7x total estimated blood volume [EBV]) compared with HypoLR (1.9x EBV) and StandLR (3.2x EBV) (P < 0.05). Although HBOC required the smallest fluid volume (0.4x EBV), survival was no better than C and it resulted in the most significant acidosis. These results support the decision to use Hextend for Hypo, a strategy currently being applied on the battlefield.
The sudden emergence of 2009 H1N1 influenza in the spring of that year sparked a surge in visits to emergency departments in New York City and other communities. A larger, second wave of cases was anticipated the following autumn. To reduce a potential surge of health system utilization without denying needed care, we enlisted the input of experts from medicine, public health, nursing, information technology, and other disciplines to design, test, and deploy clinical algorithms to help minimally trained health care workers and laypeople make informed decisions about care-seeking for influenza-like illness. The product of this collaboration, named Strategy for Off-Site Rapid Triage (SORT) was disseminated in 2 forms. Static algorithms, posted on the Centers for Disease Control and Prevention's Web site, offered guidance to clinicians and telephone call centers on how to manage adults and children with influenza-like illness. In addition, 2 interactive Web sites, http://www.Flu.gov and http://www.H1N1ResponseCenter.com, were created to help adults self-assess their condition and make an informed decision about their need for treatment. Although SORT was anchored in a previously validated clinical decision rule, incorporated the input of expert clinicians, and was subject to small-scale formative evaluations during rapid standup, prospective evaluation is lacking. If its utility and safety are confirmed, SORT may prove to be a useful tool to blunt health system surge and rapidly collect epidemiologic data on future disease outbreaks.
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