Advances made in resuscitation: current status

Abstract

To start with, coagulopathy has been shown to relate directly to the amount of fluid administered supporting the view that dilution plays a crucial role. Dysfunction of specific components and activation of protein C is connected with the exhaustion of many clotting factors [8]. Changes in pH adversely influence enzymatic function throughout the body. The degree of acidosis in the bleeding patient has been noted to correlate to the exhaustion of coagulation factors. For instance, a drop in pH from 7.4 to 7.0 decreases the activity of Factor VIIa by more than 80 % [9].It is not a surprise, therefore, that Friscknecht et al. reported that lactate >4 mmol/L odds ratio 8.70 (1.81-41.67) and pack red blood cells (PRBC) >10 units odds ratio 7.14 (1.40-40.00) were independent risk factors at ICU admission for early mortality in patients undergoing damage control management [10].For the early diagnosis of coagulopathy and the outcome of treatment, viscoelastic haemostatic assays (VHA), thromboelastography (TEG) and rotation thromboelastometry (ROTEM) representing base model assessing viscoelastic properties of coagulation in whole blood under low shear conditions have had great acceptance [11]. A graphic presentation of clot formation and subsequent lysis is obtainable following incubation of blood at 37 °C. Advantages to these diagnostic assays include assessment of combined influence of circulating plasmatic and cellular elements on clot formation and the short time that takes to make the results being available [12]. More and more trauma centers are currently using this approach of assessment and treatment of coagulation disturbances.Lately, the concept of damage control resuscitation (DCR) was introduced to optimise the resuscitation process in the multiple injured patients. The hallmark of this approach is a more focussed correction of coagulopathy and metabolic imbalances. It includes such constituents as restrictive fluidThe management of polytrauma patients has been revolutionised during the past 30 years. Major advances made in accident prevention, new car designs, rescue conditions, advanced trauma life support protocols, diagnostics, surgical approaches, intensive care support, implantology, antibiotics and pharmacotherapy in general have contributed to the overall reduction of mortality rate seen in this cohort of patients [1][2][3]. Moreover, the philosophy of damage control surgery, a process to assist resuscitation by performing surgical maneuvers of short duration in the operating theatre with a minimal invasive approach, has been successful in reducing the additional physiological burden exerted by the second hit phenomena and thus protecting the patient of developing an exaggerated immune-inflammatory response leading to early development of multiple organ dysfunction syndrome (MODS) [4][5][6].Yet, during this period of time, the three distinct peaks of mortality being at the scene of the accident (severe head injuries), first 24-48 h (uncontrolled bleeding) and days or weeks later, as a result of the m...