Hypertonic Resuscitation of Hypovolemic Shock After Blunt Trauma

Bulger, Eileen M.; Jurkovich, Gregory J.; Nathens, Avery B.; Copass, Michael K.; Hanson, Sandy; Cooper, C.; Liu, Ping Yu; Neff, Margaret J.; Awan, Asaad B.; Warner, Keir J.; Maier, Ronald V.

doi:10.1001/archsurg.2007.41

Cited by 148 publications

(128 citation statements)

References 87 publications

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“…100,[133][134][135] No pre-hospital trials concerning head-injury, conducted in the UK, could be identified. The remaining 11 studies were conducted in the USA, [136][137][138][139] (Table 25) summarising the appraisal of the four trials conducted in the UK NHS, upon which the discussion will focus, is presented below (the complete appraisal tables can be found in Appendix E (see Critical Appraisal tables). …”

Section: Resultsmentioning

confidence: 99%

“…Five investigated interventions in head-injury, four of which fluid concerned administration 128,136,140,141 and one pre-hospital intubation. 37 The final six investigated interventions in general trauma: three fluid administration, [137][138][139] one oxygen 144 and two analgesia.…”

Section: Study Purpose and Designmentioning

confidence: 99%

“…For example, Bulger et al recruited 209 adult blunt trauma patients with hypotension, but in half the time of the other two studies (2 years) and in a region with one-eighth of the inhabitants (Seattle, USA, population 621,000). 137 Therefore, it could be that, as the eligibility criteria for entry into a trial become more specific, the recruitment rate will fall.…”

Section: Recruitmentmentioning

confidence: 99%

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The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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BackgroundReconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence – with regard to ‘early neurosurgery’ in this cohort – which we sought to address.MethodsPilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). Primary outcomes: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. ‘Open-label’ secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.ResultsOverall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%;p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.ConclusionsCurrent NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating ‘early neurosurgery through bypass’ and address the challenge of reliable TBI diagnosis at the scene of injury.Trial registrationCurrent Controlled Trials ISRCTN68087745.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

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Section: Resultsmentioning

confidence: 99%

Section: Study Purpose and Designmentioning

confidence: 99%

Section: Recruitmentmentioning

confidence: 99%

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The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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“…Although the increase of serum sodium and osmolality would begin to decline 0.5 or 1 h later, the impact on the immune system could last for up to 24 h after HTS administration (Bulger et al, 2008;Junger et al, 2012;Motaharinia et al, 2015). Considering the anti-inflammatory and immunosuppressive effects of MDSCs, the rise of the MDSC count induced by HTS in the early stage should be helpful in relieving inflammation damage.…”

Section: Fig 3 Variations Of Mdscs and M-mdsc/g-mdsc Ratio In Mice Bmentioning

confidence: 99%

Distribution and differentiation of myeloid-derived suppressor cells after fluid resuscitation in mice with hemorrhagic shock

Jiang

Fang

Ling

et al. 2017

J. Zhejiang Univ. Sci. B

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Abstract:Objective: To investigate the distribution and differentiation of myeloid-derived suppressor cells (MDSCs) in hemorrhagic shock mice, which are resuscitated with normal saline (NS), hypertonic saline (HTS), and hydroxyethyl starch (HES). Methods: BALB/c mice were randomly divided into control, NS, HTS, and HES resuscitation groups. Three subgroups (n=8) in each resuscitation group were marked as 2, 24, and 72 h. Flow cytometry was used to detect the MDSCs, monocytic MDSCs (M-MDSCs), and granulocytic/neutrophilic MDSCs (G-MDSCs) in peripheral blood nucleated cells (PBNCs), spleen single-cell suspension, and bone marrow nucleated cells (BMNCs). Results: The MDSCs in BMNCs among three resuscitation groups were lower 2 h after shock, in PBNCs of the HTS group were higher, and in spleen of the NS group were lower (all P<0.05 vs. control). The M-MDSC/G-MDSC ratios in PBNCs of the HTS and HES groups were lower (both P<0.05 vs. control). At 24 h, the MDSCs in PBNCs of the NS and HTS groups were higher, while the spleen MDSCs in the HTS group were higher (all P<0.05 vs. control). The M-MDSC/ G-MDSC ratios were all less in PBNCs, spleen, and BMNCs of the NS and HTS groups, and were lower in BMNCs of the HES group (all P<0.05 vs. control). At 72 h, the elevated MDSCs in PBNCs were presented in the HTS and HES groups, and in spleen the augment turned up in three resuscitation groups (all P<0.05 vs. control). The inclined ratios to M-MDSC were exhibited in spleen of the NS and HTS groups, and in PBNCs of the NS group; the inclination to G-MDSC in BMNCs was shown in the HES group (all P<0.05 vs. control). Conclusions: HTS induces the earlier elevation of MDSCs in peripheral blood and spleen, and influences its distribution and differentiation, while HES has a less effect on the distribution but a stronger impact on the differentiation of MDSCs, especially in bone marrow.

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“…Bislang konnte allerdings auch für HTS nicht belegt werden, dass damit generell die Überlebensrate verbes sert werden kann [18,26,87]. In speziel len Situationen wie akut erhöhtem Hirn druck oder schwerem Volumenmangel wurde der Einsatz von HTS dennoch er wogen [6,17,82].…”

Section: Hypertone Kochsalzlösungunclassified

Volumentherapie bei Hämorrhagie

2014

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How fluid resuscitation has to be performed for acute hemorrhage situations is still controversially discussed. Although the forced administration of crystalloids and colloids has been and still is practiced, nowadays there are good arguments that a cautious infusion of crystalloids may be initially sufficient. Saline should no longer be used for fluid resuscitation. The main argument for cautious fluid resuscitation is that no large prospective randomized clinical trials exist which have provided evidence of improved survival when fluid resuscitation is applied in an aggressive manner. The explanation that no positive effect has so far been observed is that fluid resuscitation is thought to boost bleeding by increasing blood pressure and dilutional coagulopathy. Nevertheless, national and international guidelines recommend that fluid resuscitation should be applied at the latest when hemorrhage causes hemodynamic instability. Consideration should be given to the fact that damage control resuscitation per se will neither improve already reduced tissue perfusion nor hemostasis. In acute and possibly rapidly progressing hypovolemic shock, colloids can be used. The third and fourth generations of hydroxyethyl starch (HES) are safe and effective if used correctly and within prescribed limits. If fluid resuscitation is applied with ongoing re-evaluation of the parameters which determine oxygen supply, it should be possible to keep fluid resuscitation restricted without causing undesirable side effects and also to administer a sufficient quantity so that survival of patients is ensured.

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Hypertonic Resuscitation of Hypovolemic Shock After Blunt Trauma

Cited by 148 publications

References 87 publications

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Distribution and differentiation of myeloid-derived suppressor cells after fluid resuscitation in mice with hemorrhagic shock

Volumentherapie bei Hämorrhagie

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