Lilly M P, Gala G J, Carlson D E, Sutherland B E, Gann D S
Department of Surgery, University of Maryland, School of Medicine, Baltimore.
Ann Surg. 1992 Aug;216(2):161-71. doi: 10.1097/00000658-199208000-00007.
The authors have reported previously that small-volume resuscitation (1.8 x bled volume) with 0.9% NaCl restores blood volume and attenuates hormonal responses after large hemorrhage without correction of arterial hypotension. The authors studied the role of rate of infusion in this observation in chronically prepared dogs (aortic flow probe, right atrial pressure and volume, and arterial catheters) after 30% hemorrhage (24.1 +/- 0.4 mL/kg). After 30 minutes, subjects were observed either without treatment (no resuscitation) or with infusion of 43 mL/kg 0.9% NaCl over 3 hours by one of three protocols: (1) impulse infusion over 10 minutes, (2) variable rate infusion, bolus with tapering infusion, or (3) constant rate infusion. Significant improvement in cardiac output and in blood volume and significant decreases of vasopressin and arterial catecholamines were observed in all fluid-treated groups. This benefit was relatively independent of rate of infusion, although impulse infusion produced greater early improvement, which dissipated with time, and constant rate infusion produced better late results. In none of the fluid-treated groups were these improvements reflected in improved mean arterial pressure compared with the no resuscitation group. The authors conclude that small-volume, slow-rate saline infusion produces physiologic benefits that cannot be assessed by easily measured clinical parameters. Thus, early resuscitation after trauma could aid patients even if arterial pressure is unchanged. This benefit might be even greater in patients with uncontrolled bleeding because arterial pressure, and hence bleeding, may not be increased by resuscitation of this type. A reassessment of the value of prehospital fluid resuscitation in the injured patient is warranted.
作者之前曾报道，在大出血后，用0.9%氯化钠进行小容量复苏（失血容量的1.8倍）可恢复血容量并减弱激素反应，但无法纠正动脉低血压。作者研究了输注速率在该观察结果中的作用，研究对象为慢性制备的犬（安装有主动脉血流探头、右心房压力和容积探头以及动脉导管），这些犬在失血30%（24.1±0.4 mL/kg）后，30分钟后，观察对象分为未治疗组（未复苏）或通过以下三种方案之一在3小时内输注43 mL/kg 0.9%氯化钠：（1）10分钟内脉冲输注，（2）可变速率输注，推注后逐渐减量输注，或（3）恒速输注。在所有液体治疗组中均观察到心输出量和血容量显著改善，血管加压素和动脉儿茶酚胺显著降低。尽管脉冲输注在早期产生了更大的改善，但随着时间推移这种改善消失了，而恒速输注产生了更好的后期结果，但这种益处相对独立于输注速率。与未复苏组相比，在任何液体治疗组中，这些改善均未反映在平均动脉压的改善上。作者得出结论，小容量、低速输注生理盐水可产生生理益处，而这些益处无法通过易于测量的临床参数进行评估。因此，创伤后的早期复苏即使动脉压未改变也可能对患者有益。对于出血未得到控制的患者，这种益处可能更大，因为这种类型的复苏可能不会增加动脉压，从而不会增加出血。有必要重新评估院前液体复苏对受伤患者的价值。
