Mean arterial pressure targeted fluid resuscitation may lead to fluid overload: A bleeding-resuscitation animal experiment

Abstract

IntroductionFluid resuscitation is the cornerstone of treatment in hemorrhagic shock. Despite increasing doubts, several guidelines recommend to maintain mean arterial pressure (MAP) >65 mmHg as the most frequent indication of fluid therapy. Our aim was to investigate the effects of a MAP-guided management in a bleeding-resuscitation animal experiment.Materials and methodsAfter anesthesia and instrumentation (tbsl) animals were bled till the initial stroke volume index dropped by 50% (t0). Fluid replacement was performed in 4 equivalent steps (t1-4) with balanced crystalloid solution to reach the baseline values of MAP. Invasive hemodynamic measurements and blood gas analyses were performed after each step.ResultsMean arterial pressure dropped from tbsl to t0 (114±11 vs 76.9±16.9 mmHg, p<0.001) and returned to baseline by t4 (101.4±14.4 mmHg). From tbsl-t0 stroke volume index (SVI), cardiac index (CI) decreased (SVI: 40±8.6 vs 19.3±3.6 ml/m2, p<0.001; CI: 3.4±0.3 vs 1.9±0.3 l/min/m2, p<0.001), pulse pressure variation (PPV) increased (13.2±4.3 vs 22.1±4.3%, p<0.001). There was a decrease in oxygen delivery (464±45 vs 246±26.9 ml/min, p<0.001), central venous oxygen saturation (82.8±5.4 vs 53.6±12.1%, p<0.001) and increase in lactate levels (1.6±0.4 vs 3.5±1.6 mmol/l, p<0.005). SVI, CI and PPV returned to their initial values by t2. To normalize MAP fluid therapy had to be continued till t4, with the total infused volume of 4.5±0.8 l.ConclusionIn the current experiment bleeding led to hemorrhagic shock, while MAP remained higher than 65 mmHg. Furthermore, MAP was unable to indicate the normalization of SVI, CI and PPV that resulted in unnecessary fluid administration. Our data give further evidence that MAP may be an inappropriate parameter to follow during fluid resuscitation.

Hyperspectral Imaging for the Evaluation of Microcirculatory Tissue Oxygenation and Perfusion Quality in Haemorrhagic Shock: A Porcine Study

“…We chose this porcine shock model to evaluate the capability of HSI to detect microcirculatory resuscitation effectivity and detrimental side effects of fluid and vasopressor therapy. While aware of the limitations of MAP-targeted resuscitation therapy, we used two MAP levels as endpoints during two treatment intervals in FG and NG to identify HSI patterns that could indicate under- or over-resuscitation [ 17 ].…”

The effect of restrictive fluid management on outcomes among geriatric hip fractures: a retrospective cohort study at five level I trauma centers

“…A plethora of the reports on RFM have used animal models and obviously do not include HLOS and ICU LOS as outcomes. 8,21,[26][27][28] Another study found no difference in the HLOS for patients with RFM when compared with SFM, but used a higher cutoff volume of ,1.75 L for RFM than that used in our study. 29 Zhao et al 5 observed that the RFM group had a significantly shorter ICU and total ventilator days.…”

“…Laboratory results were examined continuously and were presented as proportion (n) with a normal result. The laboratory results included and the ranges used to define a normal result were as follows: anion gap (AGAP, 3-10), blood urea nitrogen (#24), carbon monoxide (23)(24)(25)(26)(27)(28)(29), creatinine clearance (CrCl, 0.74-1.35 for male patients, 0.59-1.04 for female patients), platelets (plt, 150,000-450000), potassium (K, 3.6-5.2), sodium (NA, 135-145), white blood cell count (4500-11000), hematocrit (38.3-48.6 for male patients, 35.5-44.9 for female patients), red blood cell count (4.35-5.65 for male patients, 3.92-5.13 for female patients), and hemoglobin (Hgb, 13.5-17.5 for male patients, 12.0-15.5 for female patients). The change in Hgb was evaluated as the preoperative result subtracted from the postoperative result.…”

Effect of cryoprecipitate transfusion therapy in patients with postpartum hemorrhage: a retrospective cohort study

“…To evaluate the effect of the use of CRYO on fluid balance at 24 h from the initial examination, we conducted a multivariate linear regression analysis adjusted for covariates, including age, hypertensive syndrome in pregnancy, fibrinogen levels, hemoglobin levels, shock index, lactic acid levels, active bleeding, APACHE II scores, and DIC Diagnostic Criteria in Obstetrics scores. The covariates were selected as potential confounders a priori based on previous studies 8 , 27 – 29 and expert opinions from a physician in the field. Moreover, we incorporated a two-way interaction term (use of CRYO*active bleeding) to assess the effect of modification of active bleeding on the relationship between the use of CRYO and fluid balance at 24 h from the initial examination.…”