State of the art of fluid resuscitation 2010: Prehospital and immediate transition to the Hospital

At the end of the 20th century, the Institute of Medicine reviewed the state of the art for combat casualty and civilian trauma care; IV saline (or crystalloid) solutions were typically the first-line therapy for hypovolemic shock patients to compensate for acute blood loss before transfusions could be safely administered. In the first decade of the 21st century, little has changed; isotonic crystalloids remain the standard of care. There is promising data on the salutary actions of several different colloid or hypertonic solutions relative to isotonic crystalloids38-43; but to date, no randomized controlled trial has reported a significant survival benefit of these novel solutions. Controlled trials indicate the benefit of hypotensive resuscitation or low-volume resuscitation in the field, in the emergency department, and in the ICU and has become an accepted method of care. Y As of 2006, there were at least 32 randomized controlled trials comparing albumin to crystalloid solutions in 8,452 critically ill patients with hypovolemia or burns and no evidence that albumin reduced mortality. Y As of 2007, there were at least 55 randomized controlled trials of colloids compared with crystalloids and no evidence that colloids reduced the risk of death compared with crystalloids in 7,754 patients with trauma, burns, or after surgery. Y As of 2008, a review of 70 trials in 4,375 patients found no evidence that any one colloid solution is safer or more effective than any other. Y Because artificial colloids are not associated with an improvement in survival and because they are more expensive than crystalloids, some have suggested that the continued use of colloids in civilian trauma patients cannot be justified outside the context of randomized controlled trials. For the military, on the other hand, colloids and other low-volume resuscitation solutions are attractive alternatives because they have unique advantages in austere environments where supplies are limited and evacuation times can be prolonged. For these logistical reasons and because of its reduced weight and size relative to saline solutions, Hextend (6% hetastarch in lactated electrolyte buffer; Hospira, Inc.) was recommended for fluid resuscitation of combat casualties. Hextend is approved by the FDA for use in hypovolemia during elective surgery. Despite these recommendations, saline solutions are still commonly used on the battlefield. Furthermore, many civilian and military clinicians avoid any artificial colloid solutions after trauma because of generalized concerns about anaphylaxis, coagulopathy,49 and/or catastrophic bleeding. There have only been a few, inconclusive studies that have addressed the coagulation profile of Hextend. There are no data on the safety and efficacy of Hextend at the doses typically used for initial trauma resuscitation. However, recent work has suggested that Hextend administered in volumes up to 1 L has no adverse effect on the coagulation profile of trauma patients.