Helm M, Hauke J, Kohler J, Lampl L
Sektion Notfallmedizin, Abteilung für Anästhesiologie & Intensivmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89070 Ulm.
Unfallchirurg. 2013 Apr;116(4):326-31. doi: 10.1007/s00113-011-2096-5.
Prompt hemorrhage control and adequate fluid resuscitation are the key components of early trauma care. However, the optimal resuscitation strategy remains controversial. In this context the small volume resuscitation (SVR) concept with hypertonic-hyperoncotic solutions is a new strategy.
This was a retrospective study in the Helicopter Emergency Medical Service over a 5-year period. Included were all major trauma victims if they were candidates for SVR (initially 4 ml HyperHaes/kg body weight, followed by conventional fluid resuscitation with crystalloids and colloids). Demographic data, type and cause of injury and injury severity score (ISS) were recorded and the amount of fluid volume and the hemodynamic profile were analyzed. Negative side-effects as well as sodium chloride serum levels on hospital admission were recorded.
A total of 342 trauma victims (male 70.2%, mean age 39.0 ± 18.8 years, ISS 31.6 ± 16.9, ISS>16, 81.6%) underwent prehospital SVR. A blunt trauma mechanism was predominant (96.8%) and the leading cause of injury was motor vehicle accidents (61.5%) and motorcycle accidents (22.3%). Multiple trauma and polytrauma were noted in 87.4% of the cases. Predominant was traumatic brain injury (73.1%) as well as chest injury (73.1%) followed by limb injury (69.9%) and abdominal/pelvic trauma (45.0%). Within the whole study group in addition to 250 ml HyperHaes, mean volumes of 1214 ± 679 ml lactated Ringers and 1288 ± 954 ml hydroxethylstarch were infused during the prehospital treatment phase. There were no statistically significant differences in the amount of crystalloids and colloids infused regarding the subgroups multisystem trauma (ISS>16), severe traumatic brain injury (GCS<9) and entrapment trauma compared to the total study group. In patients with an initial systolic blood pressure (SBP) >80 mmHg significantly less colloids (1035 ± 659 ml vs. 1288 ± 954 ml, p<0.006) were infused, whereas in patients with an initial SBP ≤ 80 mmHg significantly more colloids were infused (1609 ± 1159 ml vs. 1288 ± 954 ml, p<0.002). There was a statistically significant increase in systolic as well as diastolic blood pressure at all times of blood pressure measurement during prehospital treatment after bolus infusion of HyperHaes within the whole study group. The same applies to the subgroups multisystem trauma, severe traumatic brain injury and entrapment trauma. Minor negative side-effects were observed in 4 cases (1.2%). The mean serum sodium chloride profile on hospital admission was 146.9 ± 5.0 mmol/l, the base excess (BE) was -5.7 ± 5.3 mmol/l) and the pH was 7.3 ± 0.1.
The concept of small volume resuscitation provides early and effective hemodynamic control. Clinical side-effects associated with bolus infusion of hypertonic-hyperoncotic solutions are rare.
迅速控制出血和充分的液体复苏是早期创伤治疗的关键组成部分。然而，最佳的复苏策略仍存在争议。在此背景下，采用高渗 - 高渗胶体溶液的小容量复苏（SVR）概念是一种新策略。
这是一项对直升机紧急医疗服务进行的为期5年的回顾性研究。纳入所有符合SVR条件的严重创伤患者（初始给予4 ml高渗羟乙基淀粉/千克体重，随后用晶体液和胶体液进行常规液体复苏）。记录人口统计学数据、损伤类型和原因以及损伤严重程度评分（ISS），并分析液体量和血流动力学参数。记录负面副作用以及入院时的血清氯化钠水平。
共有342名创伤患者（男性占70.2%，平均年龄39.0±18.8岁，ISS为31.6±16.9，ISS>16者占81.6%）接受了院前SVR。钝性创伤机制占主导（96.8%），主要损伤原因是机动车事故（61.5%）和摩托车事故（22.3%）。87.4%的病例存在多发伤和复合伤。主要损伤为创伤性脑损伤（73.1%）以及胸部损伤（亦为73.1%），其次是肢体损伤（69.9%）和腹部/盆腔创伤（45.0%）。在整个研究组中，除250 ml高渗羟乙基淀粉外，院前治疗阶段平均输注乳酸林格液1214±679 ml和羟乙基淀粉1288±954 ml。与整个研究组相比，多系统创伤（ISS>16）、严重创伤性脑损伤（GCS<9）和被困创伤亚组在晶体液和胶体液输注量上无统计学显著差异。初始收缩压（SBP）>80 mmHg的患者输注的胶体液显著较少（1035±659 ml对1288±954 ml，p<0.006），而初始SBP≤80 mmHg的患者输注的胶体液显著较多（1609±1159 ml对1288±954 ml，p<0.002）。在整个研究组中，静脉推注高渗羟乙基淀粉后，院前治疗期间所有血压测量时间点的收缩压和舒张压均有统计学显著升高。多系统创伤、严重创伤性脑损伤和被困创伤亚组情况相同。4例（1.2%）观察到轻微负面副作用。入院时血清氯化钠平均水平为146.9±5.0 mmol/L，碱剩余（BE）为 -5.7±5.3 mmol/L，pH值为7.3±0.1。
小容量复苏概念可实现早期有效的血流动力学控制。静脉推注高渗 - 高渗胶体溶液相关的临床副作用罕见。
