Crystalloid is as Effective as Blood in the Resuscitation of Hemorrhagic Shock

GURDEV SINGH, F.R.C.S.,* KHALIL 1. CHAUDRY,* and IRSHAD H. CHAUDRY, PH.D.*t
Recently there has been increasing concern over transfusionrelated diseases, especially acquired immune deficiency syndrome (AIDS). The authors therefore investigated the efficacy of lactated Ringer's solution (LRS) alone as compared with blood plus LRS resuscitation on body weight change and mortality rate after severe trauma-hemorrhagic shock. Rats, 250 to 310 g (n = 85), had a midline laparotomy performed (i.e., trauma induced), the incision was closed, and a carotid artery, jugular vein, and femoral artery were cannulated. The unrestrained, nonheparinized rats were allowed to recover from anesthesia and were bled within 10 minutes to a mean arterial pressure (MAP) of 40 mmHg. This MAP was maintained by removing more blood until the animal was unable to compensate (maximal bleedout; MB). The MAP was further maintained at 40 mmHg by returning fluid (LRS) until 50% of the MB volume (MBV) was returned. The rats were then resuscitated: group 1 with LRS 4 times the MBV; group 2 with 5 X LRS; group 3 with the shed blood returned + 2 X LRS. There was no difference between the groups in the initial weights, MAP, or hematocrit (Hct), percentage of blood volume removed, time to MB, or time to end of hemorrhage. The final Hct and MAP were higher in group 3 (p < 10-6) than in either of the other groups. Body weight gain was greater in group 2 compared with either of the other groups (p < 0.05) on day 1 after hemorrhage because of edema, but no differences were seen on subsequent days. There were no differences in the survival of animals in the different groups. These results suggest that there should perhaps be a higher threshold for blood transfusion in the management of severe trauma-hemorrhagic shock than is currently practiced.
From the Shock and Trauma Research Laboratories,

*Department of Surgery and tPhysiology, Michigan State
University, East Lansing, Michigan

T n RAUMA CONTINUES TO be a major problem and is the leading cause of death between the ages of 1 and 44 in the United States.' One halfof deaths occur from exsanguination or central nervous system trauma within 1 hour of injury, and within a further 1 to 2 hours another 30% of deaths occur.2 These are due to major internal injury.2 The cornerstone of management
Supported by NIH Grant 2 R01 GM 39519. Address reprint requests to Irshad H. Chaudry, Ph.D., Department of Surgery, Michigan State University, B424 Clinical Center, East Lansing, MI 48824. Accepted for publication November 4, 1991.

of hemorrhagic shock is identification of the source of bleeding and its control, and rapid fluid transfusion to maintain the circulating volume. Plasma and blood were the replacement fluids ofchoice until the early 1960s, when the classic work of Shires et al.3 demonstrated the superiority of a crystalloid solution combined with whole blood over whole blood alone or with the addition of plasma to the shed blood. During the Vietnam war, it was thought that infusions of colloid were necessary to prevent the adult respiratory distress syndrome,4 but it subsequently has been shown that posttraumatic pulmonary insufficiency is more correlated with sepsis than with the type of fluid used in resuscitation.5 Current practice in the United States involves transfusing crystalloid in the first instance' and using the "transfusion trigger" of a hematocrit (Hct) of 30%6 to decide when to give blood in addition. This figure of an Hct of 30% is arbitrary, however, and Hcts as low as 10% to 15% have been well tolerated.7 Also, there are several problems associated with blood transfusion, including hyperkalemia,8 acid-base imbalances,9 etc. The most emotionally charged concern is the transmission of the acquired immune deficiency syndrome (AIDS) virus.'0 In view of this, we investigated the efficacy of crystalloid alone as compared with a combination of whole blood and crystalloid resuscitation on body weight change and death after severe hemorrhagic shock.
Materials and Methods Hemorrhage Procedure Male Sprague-Dawley rats (Charles River, Wilmington, MA), 250 to 310 g (n = 85), were fasted overnight but allowed water ad libitum. They were lightly anesthetized

377

time to maximum bleedout (TMB).3 18.9 61. the final MAP and Hct were recorded and the animals were lightly anesthetized with ether. ANOVA..9 61.2%).4 minutes). and initial (IMAP) and final (FMAP) mean arterial pressure between group 1 (resuscitation [Rx] with 4 times [X] shed blood volume in the form of lactated Ringer's solution [LRS]).8 ± 2. group 3 = 120. Parsippany. the following were noted: The total circulating blood volume (TCBV) was calculated.3%). Final Parameters The final Hct (group 1 = 18. the abdominal incision was closed in layers and a carotid artery (for blood pressure monitoring). The results are expressed as mean ± standard error of the mean. The organs then were inspected visually to ensure the lack of damage by the cautery.1 ± 1. NJ).12% of the body weight.4 43. .1 ± 0. This was true even if the animals were divided into survivor and nonsurvivor subgroups and compared as such within each group or between each group (Tables 2 and 3). percentage of blood volume removed (60.7* 118.9 40.9 ± 0. Mean ± SEM.5 101.1 ±0.9 ± 1.2 107. After this.7%) and the final MAP (group I = 88.9 ± 0. decannulated. CHAUDRY. MB).6 ± 2.7 g).4 120.6 0.4 99. and Comparison of initial body weight. Surg. and the wounds were resutured.3 ± 0.8 ± 0. time to maximal bleedout (44. The animals were weighed daily. This pressure was maintained by removing more blood in increments of 0.7 ± 1.5 27 Group 3 282. The portion of the PE tubing inserted into the vessel was narrowed by extrusion to decrease the internal diameter by approximately 50% to prevent clot formation in the tubing.1 ±0. time to end of hemorrhage (103.9 ± 0.4 ± 0. and the chi square test. nonheparinized rats then were allowed to recover from anesthesia.4 ± 0. and survival was noted each day. * = p < 10-6 compared with the other two groups. or initial MAP (1 18. Having recorded the initial mean arterial pressure (MAP) and the Hct. Comparison of the Parameters Measured in all Animals Parameter Group 1 287.0 ± 2. Group 3 (n = 21) received the shed blood (kept in the heparinized syringes) back over 45 minutes followed by a further 2X over 60 minutes (blood-back resuscitation). the animals were bled (by withdrawing the blood into a heparinized syringe to prevent clotting) over the course of 10 minutes to an MAP of 40 mmHg.7 86. and group 3 (Rx with blood-back + 2X LRS). group 3 = 39. and the ether cone was removed while a 5-cm midline laparotomy was performed using an electric cautery (i.5 39.4%. initial hematocrit (41.e.2-mL increments until 50% of the shed blood volume was returned in that form (end of hemorrhage. jugular vein (for fluid replacement). percentage of total blood volume removed (% TBVR).1 ± 1.2 minutes).8 ± 0. Group 2 (n = 27) received 3X LRS over 45 minutes followed by a further 2X over 60 minutes (5X resuscitation).1 ± 1. The time taken to EH was recorded.5 ± 0. EH).2 117.4±0. At this point.6 ± 2. Table 1). one-way ANOVA.5 mmHg. group 2 = 17.3 44. as previously described by Hauptman et al.3 45.1 mmHg) were significantly higher in the blood-back group (group 3) than in either of the TABLE 1.2%. Tukey's.8 ± 3.0 84.5 60. Statistical Analysis Statistical analyses were performed using one-way analysis of variance (ANOVA). and femoral artery (for bleeding) were cannulated using PE 50 tubing (Clay Adams.0 ± 0. The jugular and carotid catheters were tunneled subcutaneously to the dorsal cervical region. Results Initial Parameters There was no statistical difference between the groups in the starting weights (282. April 1992 - with ether.5 17. trauma was induced).378 SINGH. and blood pressure was monitored with a saline manometer through the carotid catheter. This was recorded as the percentage total blood volume removed (%TBVR). Differences were considered significant at p < 0. They were allowed to recover from the anesthetic and placed in individual cages with free access to food and water. initial (IHct) and final (FHct) hematocrit.0 ± 2. The percentage data were subjected to arcsine transformation before statistical analysis was performed. the shed blood volume as a percentage of the TCBV was calculated.8 ± 0. The time taken to reach MB was recorded.6 ± 3." to be 6.2 mL until the animal was no longer able to maintain its blood pressure (maximal bleedout. the blood pressure was further maintained at 40 mmHg by returning fluid in the form of lactated Ringer's solution (LRS) in 0.5 mmHg.1 mmHg.7 ± 1.2 ± 1.2 44.0 120. Tukey's test.5 ± 0. group 2 = 84.. At the end of resuscitation.8 ± 1.6 ± 0.1 ± 0.1 37 Group 2 275. Resuscitation Procedure The rats then were divided into one of three groups: group 1 (n = 37) received LRS 3 times the shed blood volume over 45 minutes followed by a further IX over 60 minutes (total of 4X resuscitation).8 ± 1. time to end of hemorrhage (TEH).1* 21 Weight (g) %TBVR TMB (min) TEH (min) IHct (%) FHct (%) IMAP(mmHg) FMAP (mmHg) n Parameters Determined In addition to the parameters mentioned above. The unrestrained. AND CHAUDRY Ann.3 ± 0. group 2 (Rx with 5X LRS).4 40.05.

8 ± 0.1 ± 1. time to end of hemorrhage (TEH). No statistical differences were seen in the percentage weight change each subsequent day after hemorrhage (maximum loss of 7.7 61.0 60. but no statistical differences were seen within the groups between survivors and nonsurvivors. Tukey's test.2 1. * = p < 10-6 compared with the other two groups.5 12 Group 2 276.17 ± 0.Vol.5 40.4 43.7 ± 2. The reason for the initial weight gain in group 2 is the edema due to fluid overload. the change in body weight in group 2 (+4. percentage of total blood volume removed (% TBVR). finally dispelled the toxemia theory of shock.3 ± 1.7 40.8 ± 2.5 101.2 115. In 1899.5 25 Group 2 275. This same trend was seen in the survivor and nonsurvivor subgroups (Tables 2 and 3).6%.72%.7 96. and initial (IMAP) and final (FMAP) mean arterial pressure between group 1 (resuscitation [Rx] with 4 times [X] shed blood volume in the form of lactated Ringer's solution [LRS]).32% of the body weight on day 3) between the groups or within the groups between survivors and nonsurvivors.4 ± 0.5 ± 2.4 121.2 ± 0. the treatment of hypovolemic shock during World War I remained seating the patient upright and bleeding him until he was unconscious because shock was thought to be due to a circulating toxin. Comparison of the Parameters Measured in Survivors Parameter Weight (g) % TBVR TMB (min) TEH (min) IHct (%) FHct(%) IMAP(mmHg) FMAP (mmHg) n Group 1 288.'4 In 1930.80 ± 0.6 84.93 TABLE 3.0* 116. group 2 (Rx with SX LRS).7 ± ± ± ± ± ± ± ± ± 1.9 ± 2. Group 1 = resuscitation (Rx) with 4 times (X) the shed blood volume with lactated Ringer's solution (LRS).7 ± 2. time to end of hemorrhage (TEH).2 81.6 ± 0.7 3.1 0.2 ± 0.3 93. percentage of total blood volume removed (% TBVR).3 104.1 ± 1.0 13 Group 3 284. Weight (g) % TBVR TMB (min) TEH (min) IHct (%) FHct (%) IMAP (mmHg) FMAP (mmHg) n 2.3 ± 0.12 was the first to demonstrate the use of intravenous saline solution to treat hypovolemic shock. 1) than in either of the other two groups (group 1 = 1.4 83. Fig. -2 -4 -6 -8 -10 0 1 2 3 4 5 6 7 8 Days post-hemorrhage crystalloid resuscitation groups (ANOVA.8 1. ANOVA.2 ± 0.0 ± 5.4 ± 1.4 ± 1.8* 1.8 17. Tukey's test.42 ± 0.0 ± 0.5 18. A Comparison ofthe Parameters Measured in Nonsurvivors FIG.3 41.4 118.27%) was significantly higher (p < 0.9 121. and initial (IMAP) and final (FMAP) mean arterial pressure between group 1 (resuscitation [Rx] with 4 times [X] shed blood volume in the form of lactated Ringer's solution [LRS]).7 ± 3. the demonstration by Blalock'5 that the cause oftraumatic shock was hypovolemia.9%. and group 3 (Rx with blood-back + 2X LRS).2 60.46%).3 14 Group 3 10 8 6 o 282. which is cleared by the second day after hemorrhage.7 40.9 ± 0. arcsine transformation followed by ANOVA. 4 RESUSCITATION IN TRAUMA-HEMORRHAGIC SHOCK 379 TABLE 2.1 ± 0.3 ± 0.9 49. arcsine transformation.05.6 ± 0. group 2 = 51.2 44. arcsine transformation followed by ANOVA.1 ± 4.5 39. Discussion Latta. p < 10-6.6 120. and the experience gained in the management of casualties in World War II.3 18. in 1832.6 0.8 88.2 ± 2. group 3 = shed blood-back + 2X LRS.4 45.7 0. Mean ± SEM.) *_4 Comparison of initial body weight. Since then there have . The change in weight on day 1 after hemorrhage in group 2 is significantly different (* = p < 0.7 ± 0. initial (IHct) and final (FHct) hematocrit. Despite this. followed by ANOVA) compared with either of the two other groups.4 44.5 43.4* 15 4 2 o a. 1.3 39.9 ± 2.6 ± 0. No statistical differences were seen in the percentage survival ofthe animals each day after hemorrhage between the groups (group 1 = 67.2 117. Tukey's test.9 ± 0. 215-No.5 44.9 ± 0. and group 3 (Rx with blood-back + 2X LRS). 2). ANOVA. Mean ± SEM. Group 3 = -2. * = p < 10-6 compared with the other two groups. time to maximum bleedout (TMB). group 2 (Rx with 5X LRS).6 ± 2.4 ± 4. time to maximum bleedout (TMB). Daily Body Weight and Mortality Rates On day 1 after hemorrhage.2 ± 0.5 ± 4.4% on day 7 after hemorrhage.5 61.00 ± 1. chi square test.7 ± 0. Table 1). group 2 = Rx with SX LRS.7 122. initial (IHct) and final (FHct) hematocrit.4 ± 4.7 17.6 60.2 109.3 ± 0.05. Daily percentage weight change (mean ± SEM) after hemorrhage and resuscitation (see Materials and Methods for hemorrhage and resuscitation procedure). Crile'3 showed that the maintenance of an adequate circulating volume and central venous pressure with an intravenous infusion of warm saline resulted in reduced mortality rate in experimental hemorrhagic shock.7 106.6 61.5 6 Comparison of initial body weight.5 44. group 3 = 71. Parameter Group 1 285. Fig. No subsequent statistical differences are seen.4 ± 0.

For this reason.0 ± 2.1 . although there was increased oxygen-carrying capacity in the bloodback group.5 Current practice in the United States is to resuscitate with LRS followed by blood several problems with the use of blood and blood products. 2). The high incidence of pulmonary insufficiency seen in the severely injured in the Vietnam war led many investigators to believe that infusions of colloid were necessary to prevent the adult respiratory distress syndrome.6 ± 2.23 found that increasing the hematocrit above 35% by re-transfusion ofblood decreased survival in dogs after hemorrhagic shock... when Shires et al. group 2 = Rx with 5X LRS... the benefits appear to have been outweighed by the increase in blood viscosity. AND CHAUDRY 1001 Ann... .. there was no difference in the change in daily body weights at day 1 after hemorrhage (Fig. Stephan et al..7%) resuscitated group was significantly higher (p < 10-6).3 ± 0.1 ± 1. This was cleared by the second post-hemorrhage day. in other words.3 clearly demonstrated the need to replace the extracellular fluid deficit with crystalloid solutions as well as the intravascular fluid losses. This is a significant trauma. * April 1992 90 80 70 --I V.'7 showed that survival was markedly improved after hemorrhagic shock if dogs were resuscitated with LRS and donor blood rather than shed blood alone. 1).6 ± 0.. This also may affect the supply of nutrients to the tissues and the removal of the products of metabolism. which plays a major role in the outcome of the animals after hemorrhage. The present study demonstrates that there is no difference in the survival of rats after trauma (laparotomy) and severe hemorrhage when they are resuscitated with LRS alone or with a combination of blood and LRS (Fig.~ ~~7.4%) LRS-resuscitated groups. and suggested that the reason for this may be increased blood viscosity.2' also have shown that laparotomy alone produces a marked depression in cell-mediated immunity. Furthermore.. Thus.. it was 60% if laparotomy was performed before hemorrhage. however. The reason for the weight gain in group 2 on the first day after hemorrhage was edema due to fluid overload.. leading to increased mortality rate in the blood-back group. This is not surprising because it is known that LRS rapidly enters the extravascular space. comparing crystalloid alone with a combination of blood and crystalloid. group 3 = shed blood-back + 2X LRS.5 mmHg) LRS-resuscitated groups. and these are currently cause for concern. Jenkins et al.. SINGH.. Surg.-4 0 U) 0 - 4x LRS 5x ~~~~~0LRS V7 Blood + 2x LRS 0 n v 0 1 2 3 4 5 6 7 Days post-hemorrhage FIG.. .3 recommended its use in the resuscitation of hypovolemic shock..1 co -I 60 50 40 30 20 10 .. we decided to investigate resuscitation after severe hemorrhagic shock as necessary.'8 in 1950.1 mmHg) than in either the 4X (86. Also.1 . we found that there was no significant difference between the final Hcts of the 4X (18. After hemorrhage and resuscitation. suggested that it was the excessive infusion of salt solutions that was the cause of congestive atelectasis seen frequently after severe hemorrhagic shock. Crowell et al..'9 It subsequently has been shown that post-traumatic pulmonary insufficiency is more correlated with sepsis than with the type of fluid used in resuscitation. The reason for the lack ofbenefit ofblood resuscitation may lie in the viscosity of the circulating blood. a 5-cm laparotomy incision. Studies in our laboratory have demonstrated that whereas the mortality rate was only 10% after hemorrhage and resuscitation in the absence of such trauma.. Crowell and Read24 have demonstrated that there is hypercoagulability after resuscitation of animals with shed blood. we used a model of surgical trauma.. and this is one of the reasons Shires et al. been vogues and controversies as to the type of fluid that should be used for resuscitation.... . Despite this. 2..1 mmHg) or the 5X (84. but that of the blood + 2X LRS (39. They suggested that this may be due to release of microthrombi into the circulation.' There are...2%) LRS and 5X (17.22 Thus the model used in this study involved not only hemorrhage..380 . We found that the final MAP was significantly higher (p < 10-6) in the group of animals resuscitated with blood and LRS (120. Group 1 = resuscitation (Rx) with 4 times (X) the shed blood volume with lactated Ringer's solution (LRS). especially with the problems associated with transfusion-transmitted AIDS.8 ± 0. CHAUDRY. but also significant tissue trauma (5 cm laparotomy). Wolfmann et al. No differences in the daily percentage of animals still living after hemorrhage and resuscitation were seen between any of the groups (see Materials and Methods for hemorrhage and resuscitation procedure). Livingston and Malangoni20 have shown that even a 1-cm skin incision before or after hemorrhage increases infection in the rat. In this study.4"6 A combination of plasma and blood was the replacement regimen ofchoice until the early 1960s.

27'28 Furthermore. Acknowledgments The authors wish to thank Ms Renee Ziobron for her skill and patience in the editorial stages of this manuscript. 4 RESUSCITATION IN TRAUMA-HEMORRHAGIC SHOCK 381 however. 249:28-35.' 0 In 1987. Trunkey DD. and hyperkalemia may occur during the rapid phase of transfusion.39 but to put this in perspective.33 The concentration of potassium in the plasma of stored blood increases with time. 2. We found that there was no statistical difference in the mortality rate and no differences in weight change at day 2 after hemorrhage between these different resuscitation regimens. Carrico J.35 Stored blood develops particulate debris consisting of microaggregates of platelets. therefore. California: Appleton and Lange. McAuley CE. even if they were not so expensive and in relative short supply.30 3' There is an excess of citrate in stored blood to completely bind calcium and prevent clotting and. have shown that Hcts of 10% to 15% in animals subjected to acute hemodilution were well tolerated. resuscitated hemorrhagic shock and "shock lung": an experimental correlation. and fibrin. Surg Gynecol Obstet 1982. References 1. Esrig BC.Vol. there was no difference in the survival of the animals in the three groups." but dilution is only a small part of the problem. Krupski WC.um blood infusion filters and may result in pulmonary insufficiency.7 in graded hemodilution studies. Meredith JW. Fluid therapy in hemorrhagic shock. 6. 4. Pelton JJ. Bergin JJ.34 Hypothermia is a complication of the massive transfusion of refrigerated blood.. Moreover. The results of the study presented here are of significance especially in the present climate of attempting to avoid the transfusion of blood and blood products. it appears that blood transfusion is not always necessary in the management of hemorrhagic shock. they suggest that hemodilution may even be beneficial during reperfusion after ischemia. Coln D. Cheu HW. Pelton et al. 7. some of which are too small to be removed by standard 1 70-. leading to several clinical problems. This is commonly known as "dilutional coagulopathy. 8th Edition. 154:577-586. This may lead to acid-base imbalances. 215 .26 Similar observations concerning cardiac output and hemodilution have been reported by others. There are several potential problems associated with the use of blood and blood products. The commonly used "transfusion trigger" Hct of 30%6 is arbitrary and. Pennell T. 17:327-335.6'25 There has been concern expressed about erythrocyte replacement because transfusion ofcrystalloids alone will diminish the oxygen-carrying capacity of blood after significant blood loss.29 It should be pointed out that we are not advocating that blood never be used in the resuscitation of hypovolemic shock. 3. Poole GV. Indeed. Transfusion therapy in emergency medicine. Ann Emerg Med 1988. Trauma. Current Surgical Diagnosis and Treatment. however. this is rapidly metabolized in the liver. We have recently shown. San Mateo. thereby decreasing the delivery of oxygen to tissues. and this is in agreement with the suggestions of other investigators. These results suggest that the "hematocrit trigger" for transfusion should perhaps be lowered to 20%. 886 cases of transfusion-associated AIDS had been reported. that hepatocellular dysfunction occurs early after hemorrhage and persists despite fluid resuscitation. we compared the weight changes and mortality rates in rats subjected to trauma and severe hemorrhagic shock and resuscitated with either LRS alone or with blood plus LRS. more than 10 million transfusions are given yearly. Ann Surg 1975. and chronic hepatitis develops in as many as 50% of the affected individuals. Trunkey DD.9 Storage of blood increases the 2.6 In summary. The limit of hemodilutional .36 Antibodies present in the recipient's plasma and directed against foreign transfused red cell antigens can cause serious problems and even death. Mintz PD. leukocytes. ed. Mesh and Gewertz.29 in an intestinal ischemia model. Sci Am 1983. Hcts as low as 10% to 15% have been well tolerated. The most serious problem in terms of frequency and complications is non-A. Platelet and coagulation factor deficiencies are seen in some patients after a massive blood transfusion and may lead to a bleeding diathesis. 88:688-693. but suggesting that the threshold for its use may perhaps be higher than at present. et al. Comparison ofcolloids and crystalloids in resuscitation from hemorrhagic shock.38 The most serious problem in terms of public concern is the possible transmission of the AIDS virus. Lightfoot S. Fulton RL. 182: 218-227.7 This is in agreement with our findings that a hematocrit of 15% to 20% was no more detrimental to the survival of animals subjected to severe traumahemorrhagic shock than that ofanimals with Hcts of 35% to 40%.32 This may be part of the explanation for the hypocalcemia seen after blood transfusion. 5. non-B hepatitis. Lewis FR. Recent studies in this laboratory have indicated that 50% acute hemodilution with LRS in shamoperated animals did not significantly affect cardiac output. Thus.37 Probably the most emotionally charged complication of transfusion of blood and blood products presently is the possibility of transfusion-transmitted diseases. under normal circumstances. have demonstrated that hemodilution has no adverse effects on oxygen consumption during hypotension and hypoperfusion. as pointed out previously. Arch Surg 1964.No. Shires T. Kruskall MS. 1988:187-209. Mills SA. Evidence for the infection can be found in as many as 7% of transfusion recipients within 6 months of the transfusion. Management of the injured patient. Sepsis.3-DPG level of erythrocytes and this decreases the affinity of hemoglobin for oxygen. In: Way LW.8 Banked blood is acidic because of the citrate anticoagulant and becomes more acidic with storage as lactic acid accumulates.

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