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Fluid therapy for the traumatized patient

Authors

  • Bernd Driessen DVM, Dr. med. vet., DACVA, ECVPT,

    1. From the Section of Critical Care and Anesthesia, Widener Large Animal Hospital, New Bolton Center
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  • Benjamin Brainard VMD

    1. Section of Critical Care, Mathew J. Ryan Veterinary Hospital
    2. School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, and David Geffen School of Medicine at University of California-Los Angeles, Department of Anesthesiology, Los Angeles, CA
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Address correspondence and reprint requests to:
Dr. Bernd Driessen, University of Pennsylvania, School of Veterinary Medicine, 382 West Street Road, Kennett Square, PA 19348.
E-mail: driessen@vet.upenn.edu

Abstract

Objective: To review the rationale behind and experiences with traditional and newly evolving concepts of fluid therapy in the traumatized patient, and to review conventional and novel fluid preparations for use in trauma resuscitation.

Data sources: Human and veterinary clinical and research studies.

Human data synthesis: Current treatment guidelines recommend aggressive fluid resuscitation with lactated ringers solution (LRS) or saline as optimum management of hemorrhagic shock in trauma, regardless of whether bleeding is controlled or not. The rationale behind this strategy is to restore intravascular volume as rapidly as possible to ensure adequate vital organ perfusion. Recently, this strategy has been challenged, especially in patients with uncontrolled hemorrhage, as neither laboratory evidence nor clinical trials support this practice. Current research indicates that vigorous fluid infusion may exacerbate bleeding and cause severe hemodilution, both impairing resuscitation outcome. As a result, a new line of thinking is emerging that balances the risks and benefits of intravenous volume infusion by offering the clinician alternative treatment strategies and emphasizes continuous endpoint-oriented monitoring. ‘Hypotensive’ or ‘hypovolemic’ resuscitation techniques as well as initial volume replacement with fluids other than LRS or saline (e.g., hypertonic saline [HTS], HTS with dextran 70 [HTS-D]) have been introduced in human medical practice as additional options for treatment of victims of trauma under certain circumstances. Clinical studies evaluating the use of hemoglobin-based oxygen carriers (HBOCs) in the trauma setting are underway and may soon lead to an expansion of the fluid arsenal available to the clinician for treatment of trauma patients.

Veterinary data synthesis: Based on available animal data, neither strict guidelines nor a clear fluid preference for resuscitation of traumatic shock have been defined. Although systematic clinical trials are missing, combinations of crystalloid and colloid (natural or artificial) appear to be as effective for resuscitation as crystalloid alone. Judicious use of an HBOC (e.g., Oxyglobin®) as a substitute for blood/red blood cells may be recommended in situations where whole blood or pRBCs are not or not yet available.

Conclusions: The search for optimal methods of fluid resuscitation in trauma is ongoing. At this point the best solution is a differentiated approach to fluid therapy, one that tailors type and volume of resuscitation solution(s) used to the type and severity of injury in an individual patient and uses monitoring of perfusion and oxygenation parameters to guide resuscitation. Crystalloid fluids are effective for resuscitation but may need to be combined with or replaced by colloidal fluids in certain clinical situations.

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