Serum potassium increase accompanies the onset of HS. The rise in serum potassium was directly related to the hemodynamic deterioration of HS and strongly correlated with markers of tissue hypoxia.

OBJECTIVE:This study was designed to evaluate the effects of terlipressin versus fluid resuscitation with normal saline, hypertonic saline or hypertonic-hyperoncotic hydroxyethyl starch, on hemodynamics, metabolics, blood loss and short-term survival in hemorrhagic shock.METHOD:Twenty-nine pigs were subjected to severe liver injury and treated 30 min later with either: (1) 2 mg terlipressin in a bolus, (2) placebo-treated controls, (3) 4 mL/kg 7.5% hypertonic NaCl, (4) 4 mL/kg 7.2% hypertonic-hyperoncotic hydroxyethyl starch 200/0.5, or (5) normal saline at three times lost blood volume.RESULTS:The overall mortality rate was 69%. Blood loss was significantly higher in the hypertonic-hyperoncotic hydroxyethyl starch and normal saline groups than in the terlipressin, hypertonic NaCl and placebo-treated controls groups (p<0.005). Hyperkalemia (K>5 mmol/L) before any treatment occurred in 66% of the patients (80% among non-survivors vs. 22% among survivors, p=0.019). Post-resuscitation hyperkalemia occurred in 86.66% of non-survivors vs. 0% of survivors (p<0.001). Hyperkalemia was the first sign of an unsuccessful outcome for the usual resuscitative procedure and was not related to arterial acidemia. Successfully resuscitated animals showed a significant decrease in serum potassium levels relative to the baseline value.CONCLUSION:Hyperkalemia accompanies hemorrhagic shock and, in addition to providing an early sign of the acute ischemic insult severity, may be responsible for cardiac arrest related to hemorrhagic shock.

Background and objectives: The aim of this paper is to report a case in which the damage control resuscitation (DCR) approach was successfully used to promote hemostatic resuscitation in a polytraumatized patient with severe hemorrhagic shock. Case report: Female patient, 32 years of age, with severe hemorrhagic shock due to polytrauma with hip fracture, who developed acidosis, coagulopathy, and hypothermia. During fl uid resuscitation, the patient received blood products transfusion of fresh frozen plasma/packed red blood cells/platelet concentrate at a ratio of 1:1:1 and evolved intraoperatively with improvement in perfusion parameters without requiring vasoactive drugs. At the end of the operation, the patient was taken to the intensive care unit and discharged on the seventh postoperative day. Conclusion: The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defi ned therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.

The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defined therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.

During orthotopic liver transplantation for fulminant hepatic failure, some patients may develop sudden deterioration of cerebral perfusion and oxygenation, mainly due to increased intracranial pressure and hypotension, which are likely responsible for postoperative neurological morbidity and mortality. In the present study, we hypothesized that the favorable effects of hypertonic saline solution (NaCl 7.5%, 4 mL/kg) infusion on both systemic and cerebral hemodynamics, demonstrated in laboratory and clinical settings of intracranial hypertension and hemorrhagic shock resuscitation, may attenuate the decrease in cerebral perfusion pressure that often occurs during orthotopic liver transplantation for fulminant hepatic failure. METHODS: 10 patients with fulminant hepatic failure in grade IV encephalopathy undergoing orthotopic liver transplantation with intracranial pressure monitoring were included in this study. The effect on cerebral and systemic hemodynamics in 3 patients who received hypertonic saline solution during anhepatic phase (HSS group) was examined, comparing their data with historical controls obtained from surgical procedure recordings in 7 patients (Control group). The maximal intracranial pressure and the corresponding mean arterial pressure values were collected in 4 time periods: (T1) the last 10 min of the dissection phase, (T2) the first 10 minutes at the beginning of anhepatic phase, (T3) at the end of the anhepatic phase, and (T4) the first 5 minutes after graft reperfusion. RESULTS: Immediately after hypertonic saline solution infusion, intracranial pressure decreased 50.4%. During the first 5 min of reperfusion, the intracranial pressure remained stable in the HSS group, and all these patients presented an intracranial pressure lower than 20 mm Hg, while in the Control group, the intracranial pressure increased 46.5% (P < 0.001). The HSS group was the most hemodynamically stable; the mean arterial pressure during the first 5 min of reperfusion increased 21.1% in the HSS group and decreased 11.1% in the Control group (P < 0.001). During the first 5 min of reperfusion, cerebral perfusion pressure increased 28.3% in the HSS group while in the Control group the cerebral perfusion pressure decreased 28.5% (P < 0.001). Serum sodium at the end of the anhepatic phase and 3 hours after reperfusion was significantly higher in the HSS group (153.00 ± 2.66 and 149.00 ± 1.73 mEq/L) than in the Control group (143.71 ± 3.30 and 142.43 ± 1.72 mEq/L), P = 0.003 and P < 0.001 respectively. CONCLUSION: Hypertonic saline solution can be successfully used as an adjunct in the neuroprotective strategy during orthotopic liver transplantation for fulminant hepatic failure, reducing intracranial pressure while restoring arterial blood pressure, promoting sustained increase in the cerebral perfusion pressure.

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Durante anestesia geral balanceada com infusão contínua de remifentanil para realização de laparotomias, temos sido alertados pela equipe cirúrgica da ocorrência de expressiva redução no diâmetro das alças intestinais. Conforme relato, essa diminuição pode dificultar a realização de anastomoses entéricas. O remifentanil, opióide mais recentemente introduzido na prática clínica, tem como principal vantagem permitir analgesia rápida, intensa e titulável [1][2][3][4] . Apesar do conhecimento de que os opióides possam comprometer a função gastrintestinal, na literatura não há relatos da possibilidade de alteração no tamanho das alças intestinais durante a utilização do remifentanil 4,5 . Considerando a observação da equipe cirúrgica, desenvolvemos projeto de pesquisa clíni-co para avaliação da hipótese de efeito indesejável do remifentanil sobre o diâmetro das alças intestinais. Após a aprovação pela Comissão de Ética institucional e assinatura do termo de consentimento livre e esclarecido, realizamos medidas do diâmetro das alças jejunais antes e após infusão contínua de remifentanil em dois pacientes adultos submetidos à hepatectomia. Foram excluídos pacientes que apresentassem fatores de interferência na contratilidade intestinal, como diabetes melito, neuropatias periféricas, insuficiência renal crônica, doença de Chagas, doença inflamatória intestinal, colagenoses, desnutrição grave, síndromes de má-absorção, jejum por tempo superior a 48 horas ou ocorrência de náuseas, vômitos ou diarréia no pré-operatório. O diâmetro das alças intestinais foi aferido utilizando-se um paquímetro mecânico de aço inoxidável (Starrett ® ) esterilizado e calibrado em milímetros. O mesmo cirurgião realizou as medidas em local predeterminado e marcado com verdebrilhante, 20 cm após o ângulo duodenojejunal. A primeira medida foi feita logo após a abertura da cavidade abdominal, antes do início da infusão contínua de remifentanil e a segunda foi aferida após 120 minutos do início da infusão contínua desse fármaco. A anestesia geral balanceada foi induzida com propofol 1,5 a 2,5 mg.kg -1 , sufentanil 0,25 a 0,5 µg.kg -1 e cisatracúrio 0,15 mg.kg -1 . A manutenção foi feita com isoflurano em concentração expirada de até 1,2% e o bloqueio neuromuscular mantido com bolus de 10% a 20% da dose inicial de cisatracúrio, quando necessário. Após a medida inicial do diâmetro intestinal, iniciou-se infusão contínua do remifentanil (0,5 µg.kg -1 .min -1 ), titulada conforme estímulo cirúrgico.

: The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defined therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.