Clinical Application Of Limited Fluid Resuscitation In Hemorrhagic Traumatic Shock

Trauma is the destruction of tissues or organs caused by mechanical factors when act on body. Trauma not only happens in the wartime, but also takes place in peaceful period. Due to the rapid development of industry, agriculture, transportation and other industries, the incidence of traumatic events of all kinds get to be on a rise. According to the data announced by the Traffic Management Bureau of Public Security Ministry, during the 40 years at the end of 20th century, traffic accidents and casualties caused by them got an increase by about 30 times to 50 times[37].In particular, multiple trauma, characterized by its urgent state, severe injury, quickly changing, high mortality, high rate of misdiagnosis, have been got attention gradually by emergency medicine and surgical doctors. Data shows that the incidence of multiple trauma could go beyond 70% in the wartime, and in a city explosion accident in normal times, the incidence of multiple trauma could often get more than 50% [34].Therefore, at the same time of modern civilization, the normal lives of people are still threatened by unexpected emergency, in face of severe trauma, multiple trauma, enhancing the emergency medical treatment of emergency personnel, will help raise the survival rate of patients, improve the prognosis and quality of life.Shock often happens accompany with severe multiple trauma. A domestic report shows that the incidence rate of shock was 84.9% in 1216 cases with severe multiple trauma. The high incidence of shock can be seen from the data. If not corrected in time, shock continues to develop, would cause secondary damage of internal organs, such as acute respiratory distress syndrome(ARDS),multiple organ dysfunction syndrome(MODS) even caused multiple organ failure or death. For the fluid resuscitation of severe multiple trauma with hemorrhagic shock, traditional point advocated early and aggressive fluid resuscitation to restore effective blood volume as soon as possible, prompt and maintain the blood pressure to normal range so as to guarantee the organ perfusion and tissue oxygen delivery. This method had saved innumerable shock patients'life. In recent years, with continuous deeper research of hemorrhage shock, there is new realization on the resuscitation of shock. Different animal experiments and clinical researches[16,17,18] have demonstrated that serious results would appear when giving aggressive and rapid fluid resuscitation, such as clot formation would fall off, coagulopathy, hypothermia, hemodil-ution, low oxygen delivery of tissue, worse of acidosis and rebleeding, et al.Scholars proposed the concept of"limited fluid resuscitation"or"delayed fluid resuscitation","hypotensive fluid resuscitation", which has a viewpoint that neither advocate positive fluid resuscitation with large volume, nor recover the blood pressure to normal range for uncontrolled hemorrhagic shock, but only to infuse a little fluid to provide the fundamental need of body before hemostasis in the operating room, to keep the blood pressure to an acceptable scope lower than normal level. And make full fluid resuscitation after operations. Limited fluid resuscitation could avoid to disorder organism's compensate mechanism and the internal environment excessively, and could also achieve an ideal recovery effect. The study compare and analysis the difference of survival rate, mortality rate and complication formation rate among different fluid groups, to explore the best method of fluid resuscitation of uncontrolled hemorrhagic shock.114 cases, which had been got severe multiple injuried with hemorrhagic shock of uncontrolled bleeding, rescued by emergency department of our hospital between January 2005 to December 2008, were chosen in this study. Of the cases, 81 males, 33 females, aged from 20 years old to 50 years old, with an average age of 35.68±9.41 years old. Injury causes: 66 cases with traffic accident injury, 39 cases with sharp injury, 5 cases with fall injury, 4 cases with crush injury. All the cases were multiple injuries, of which 51 were abdominal injuries,35 hemopneumothorax,38 important vascular injuries,48 limb fractures, 15 pelvis fractures.In order to reduce the impact of other factors, set criteria of case selection: there is no hypertension, no coronary heart disease, and no history of major surgery or organ dysfunction. All cases were confirmed to have been bleeding of uncontrolled after injuries by surgeries or auxiliary examinations. The time of all the cases from got injuried to hospital is not more than 1 hours, and the volume of outside infusion is not more than 500ml, either. There are shocks of different degrees to all the cases when came to hospital. The injury severity score (AIS2005-ISS score) were all above 16 points, patients with brain injury were excluded, and ruled out the dead when come to hospital, or cases who died before any rescues had been done. Eligible patients are divided into full fluid resuscitation group (group A) and limited fluid resuscitation group (group B) according to different methods of fluid resuscitation. Based on the different types of recovery liquids, group B was divided into group B1(HES+LR) and group B2(HES+7.5%HS). There are 50 cases in group A, recovered by full fluid resuscitation treatment, infused LR and HES according to a ratio of 2~3:1,restored effective circulation volume as soon as possible, in order to make Mean Arterial Pressure (MAP) above 80mmHg; There are 64 cases in group B, 34 in group B1,made use of HES+LR, 30 in group B2,infused HES+7.5% HS (2 ~ 4ml/kg), kept MAP to a certain range of 50 ~ 70mmHg. Compare the difference of survival rate, mortality rate and incidence of ARDS and MODS among different recovery groups.The result showed that the survival rate of group A was 62.0%, mortality rate was 38.0%, incidence rate of ARDS was 34.0%,MODS was 26.0%;The survival rate of group B was 84.38%,mortality rate was 15.62%, incidence rate of ARDS was 12.5%,MODS was 7.81%.There is significant difference between the two groups(P<0.05);The survival rate of group B1 was 85.29%, mortality rate was 14.7%,incidence rate of ARDS was 11.76%, MODS was 8.82%; the survival rate of group B2 was 83.33%, mortality rate was 16.67%, incidence rate of ARDS was 13.33%, MODS was 6.67%. There is no significant difference between the two groups(P>0.05).But there is significant difference between the two groups in the total infusion volume ( P<0.05, respectively 945.59±97.21ml ,838.33±92.55ml);Comparing group A with group B1, group B2, there are significant difference in the survival rate, mortality rate, incidence rate of ARDS and MODS(P<0.05).This study shows that correct and timely fluid resuscitation could effectively restore the blood volume, for the severe multiple trauma patients with hemorrhagic shock of uncontrolled bleeding, and create good conditions for further treatment. Limited fluid resuscitation can improve the patients'survival rates, reduce the mortality rates, the incidence of ARDS and MODS. For the hemorrhagic shock with uncontrolled bleeding, the application of 7.5% HS can reduce the infusion volume when taking use of limited fluid resuscitation, and avoid the impact to internal environment of body due to early aggressive fluid infusion.