The Strategy For Fluid Resuscitation Of The Hemorrhagic Shock Patients With Risk Of Rebleeding

Objective To investigate the reasonable fluid resuscitation target for hemorrhagic shock patients with risk of rebleeding.Method We enrolled 48 patients with hemorrhagic shock who were admitted into intensive care unit(ICU) of Hangu Hospital of Binhaixinqu of Tianjin(renamed Binhai Hospital of Tianjin Medical University General Hospital from January 1, 2015) April 2011 to April 2014 and randomly assigned them into observation group(MAP 55~65mm Hg and SBP <95mm Hg; 1mm Hg=0.133 k Pa; n=26) and control group(MAP 65~75mm Hg and SBP <105mm Hg; n=22). Before fluid resuscitation, and 12 h, 24 h, 48 h, 72 h after resuscitation, a series of data were recorded, including level of extravascular lung water(EVLW) and blood lactic acid, length of ICU stay, duration to reach negative fluid balance, incidence of rebleeding and multiple organ dysfunction syndrome(MODS) and acute respiratory distress syndrome(ARDS), as well as 28-day mortality.Results First: There was statistical difference in the level of EVLW between the two groups(F=4.521,P<0.05), and the level of EVLW of different time was statistically different(F=56.337,P<0.001), but there was no statistical difference in the interaction effect between the group and the time(F=2.171,P>0.05). Compared with control group, observation group had lower level of EVLW at 48 h, 72 h after resuscitation(F=4.105、4.345,P<0.05), but there was no statistical difference before fluid resuscitation and at 12 h, 24 h after resuscitation between the two groups(F=0.038、0.081、0.190,P>0.05). Second: There was statistical difference in the level of blood lactic acid between the two groups(F=6.143,P<0.02), and the level of blood lactic acid of different time was statistically different(F=115.667,P<0.001), but there was no statistical difference in the interaction effect between the group and the time(F=3.900,P>0.05). Compared with control group, observation group had lower level of blood lactic acid at 48 h, 72 h after resuscitation(F=12.374、9.112,P<0.05), but there was no statistical difference before fluid resuscitation and at 12 h, 24 h after resuscitation between the two groups(F=0.044、0.769、1.068,P>0.05).Third: The length of ICU stay(8.3d vs. 11.3d, t=2.813, P<0.05) and the duration to reach negative fluid balance(5.2d vs. 6.9d, t=2.036, P<0.05) were apparently shorter in the observation group than that in the control group. But there was no statistical difference in the time to reach fluid resuscitation target between the two groups(t=1.898,P>0.05).Forth: Compared with control group, observation group had lower incidence of rebleeding(15.4% vs. 40.9%, χ2=3.931, P<0.05), MODS(15.4% vs. 45.5%, χ2=5.215, P<0.05) and ARDS(11.5% vs. 36.4%, χ2=4.157, P<0.05). There was no statistical difference in 28-day mortality.ConclusionFirst: The fluid resuscitation target of MAP 65~75mm Hg and SBP less than 95 mm Hg can reduce the duration to reach negative fluid balance and the length of ICU stay,so it is safe, reasonable and effective for hemorrhagic shock patients with risk of rebleeding.Second: For decreasing the perfusion pressure of tissue, and having less influence on the clotting mechanism and vascular contractile reactivity,limited fluid resuscitation can prevent thrombolysis and lower the rate of bleeding again.Third : For avoiding fluid overload, capillary pressure markedly elevated, and accumulation of excess fluid within the interstitial spaces, limited fluid resuscitation can prevente pulmonary edema and respiratory failure, and can lower the incidence of ARDS.Forth : For ensuring organ perfusion by properly rehydration and reducing dischemia-reperfusion injury caused by bleeding again, limited fluid resuscitation can improve tissue oxygen supply, and lower the incidence of MODS.