Not only has the optimal solution for resuscitation after traumatic injury been hotly contested, so too has the concept of resuscitation at all prior to definitive hemorrhage control [1]. The ideal resuscitation strategy following penetrating or blunt trauma associated with hypoperfusion to provide maximal survival remains to be defined. Currently, there is a trend towards limited volume resuscitation instead of aggressive crystalloid volume expansion. Vitally related to these controversies are the debated endpoints of resuscitation — physiological and metabolic markers of the adequacy of resuscitation [2]. Ideally, these markers should reflect changes in both systemic and microcirculatory flow. Increasingly evidence suggests that this is not the case. Moreover, the immunomodulatory effects of resuscitation and resuscitation fluids have influenced the casual selection of fluid type and amount for plasma volume expansion. This paper will explore the current state of trauma resuscitation ,with a particular focus on the acid-base sequelae of resuscitation, the impact of these sequelae, and their interpretation on the endpoints of resuscitation, potentially useful strategies to aid in resuscitation, and future areas of investigation.


Lactate Ringer Hydroxyethyl Starch Advance Trauma Life Support Plasma Volume Expansion Trauma Resuscitation 
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  1. 1.
    Dries DJ (1996) Hypotensive resuscitation. Shock 6:317–318CrossRefGoogle Scholar
  2. 2.
    Durham RM, Neunaber K, Mazuski JE, et al (1996) The use of oxygen consumption and delivery as endpoints for resuscitation in critically ill patients. J Trauma 41:32–39PubMedCrossRefGoogle Scholar
  3. 3.
    Mager S, De Varenes (1998) Clinical death and the measurement of stressed vascular volume. Crit Care Med 26:1061–1064CrossRefGoogle Scholar
  4. 4.
    Bickell W, Wall MJ, Pepe PE, et al (1994) Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 331:1105–1109PubMedCrossRefGoogle Scholar
  5. 5.
    Solomonov E, Hirsh M, Yahiya A, et al (2000) The effect of vigorous fluid resuscitation in uncontrolled hemorrhagic shock after massive splenic injury. Crit Care Med 28:749–754PubMedCrossRefGoogle Scholar
  6. 6.
    Abramson D, Scalea TM, Hitchcock R, et al (1993) Lactate clearance and survival following injury. J Trauma 35:584–589PubMedCrossRefGoogle Scholar
  7. 7.
    Blow O, Magliore L, Claridge JA, et al (1999) The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 47:964–969PubMedCrossRefGoogle Scholar
  8. 8.
    Claridge JA, Crabtree TD, Pelletier SJ, et al (2000) Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients. J Trauma 48:8–14PubMedCrossRefGoogle Scholar
  9. 9.
    James JH, Luchette FA, McCarter FD, et al (1999) Lactate is an unreliable indicator of tissue hypoxia in injury or sepsis. Lancet 354:505–508PubMedCrossRefGoogle Scholar
  10. 10.
    Gomersall CD, Joynt GM, Freebairn RC et al (2000) Resuscitation of critically ill patients based on the results of gastric tonometry: a prospective, randomized, controlled trial. Crit Care Med 28:607–614PubMedCrossRefGoogle Scholar
  11. 11.
    Kellum JA, Rico P, Garuba AK, et al (2000) Accuracy of mucosal pH and mucosal-arterial carbon dioxide tension for detecting mesenteric hypoperfusion in acute canine endotoxemia. Crit Care Med 28:462–466PubMedCrossRefGoogle Scholar
  12. 12.
    Millham FH, Malone M, Blansfield J, et al (1995) Predictive accuracy of the TRISS survival statistic is improved by a modification that includes admission pH. Arch Surg 130:307–311CrossRefGoogle Scholar
  13. 13.
    Rutherford EJ, Morris JA, Reed GW, et al (1992) Base deficit stratifies mortality and determines therapy. J Trauma 33:417–422PubMedCrossRefGoogle Scholar
  14. 14.
    Chang MC, Meredith JW (1997) Cardiac preload, splanchnic perfusion, and their relationship during resuscitation in trauma patients. J Trauma 42:577–584PubMedCrossRefGoogle Scholar
  15. 15.
    Henry S, Scalea TM (1999) Resuscitation in the new millennium. Surg Clin North Am 79:1259–1267PubMedCrossRefGoogle Scholar
  16. 16.
    Cosgriff N, Moore EE, Sauaia A, et al (1997) Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidosis revisited. J Trauma 42:857–862PubMedCrossRefGoogle Scholar
  17. 17.
    McKinley BA, Marvin RG, Cocanour CS, et al (2000) Tissue hemoglobin O2 saturation during resuscitation of traumatic shock monitored using near infrared spectroscopy. J Trauma 48:637–642PubMedCrossRefGoogle Scholar
  18. 18.
    Weil MH, Nakagawa Y, Tang W, et al (1999) Sublingual capnometry: a new noninvasive measurement tool for diagnosis and quantification of severity of circulatory shock. Crit Care Med 27:1225–1229PubMedCrossRefGoogle Scholar
  19. 19.
    Holm C, Melcer B, Harbrand F, et al (2000) Intrathoracic blood volume as an endpoint in resuscitation of the severely burned: an observational study of 24 patients. J Trauma 48:728–734PubMedCrossRefGoogle Scholar
  20. 20.
    Kellum JA (1998) Metabolic acidosis in the critically ill: lessons learned from physical chemistry. Kidney Int 53[Suppl 66]:S81-S86Google Scholar
  21. 21.
    Healey MA, Davis RE, Liu FC, et al (1998) Lactated ringer’s is superior to normal saline in a model of massive hemorrhage and resuscitation. J Trauma 45:894–899.PubMedCrossRefGoogle Scholar
  22. 22.
    Scheingraber S, Rehm M, Semisch C, et al(1999) Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthiology 90:1265–1270CrossRefGoogle Scholar
  23. 23.
    PICU CM articleGoogle Scholar
  24. 24.
    Patterson T, Bailey H, Kaplan LJ (2000) Hyperchloremia induces acidosis, increases the strong ion gap, and impairs coagulation. Crit Care Med 28:A118Google Scholar
  25. 25.
    Wilcox CS (1983) Regulation of renal blood flow by plasma chloride. J Clin Invest 71:726–735PubMedCrossRefGoogle Scholar
  26. 26.
    Williams EL, Hildebrand KL, McCormick SA, et al (1999) The effect of intravenous lactated ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth Analg 88:999–1003PubMedGoogle Scholar
  27. 27.
    Wilkes N, Woolf R, Stephens R, et al (2001) The effects of balanced versus saline based intravenous solutions on acid-base status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg (in press)Google Scholar
  28. 28.
    Prough DS, Bidani A (1999) Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline. Anesthiology 90:1247–1249CrossRefGoogle Scholar
  29. 29.
    Waters JH, Miller LR, Clack S, et al (1999) Cause of metabolic acidosis in prolonged surgery. Crit Care Med 27:2142–2146PubMedCrossRefGoogle Scholar
  30. 30.
    Kaplan LJ, Bailey H, Kozar R, et al (1999) Initial pH, base deficit, lactate, strong ion difference and gap, but not anion gap predict outcome from major vascular injury. Crit Care Med 27:A174Google Scholar
  31. 31.
    Kaplan LJ, Bailey H, Klein A, et al (1999) Strong ion gap: a predictor of early mortality following blunt or penetrating trauma. Crit Care Med 27:A42Google Scholar
  32. 32.
    Schierhout G, Roberts I (1998) Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomized trials. BMJ 316:961–964PubMedCrossRefGoogle Scholar
  33. 33.
    Alderson P, Hawkins V (2000) Colloid solutions for fluid resuscitation. Cochrane Database of Systematic Reviews (computer file). 2:CD001319Google Scholar
  34. 34.
    Wilkes MM, Navickis RJ (2001) No evidence of excess mortality in patients receiving human albumin: a meta-analysis of randomized controlled trials. Crit Care 5[Suppl 1]:S54Google Scholar
  35. 35.
    Burch JM (1997) New concepts in trauma. Am J Surg 173:44–46PubMedCrossRefGoogle Scholar
  36. 36.
    Garrison JR, Richardson JD, Hilakos AS, et al (1996) Predicting the need to pack early for severe intra-abdominal hemorrhage. J Trauma 40:923–929PubMedCrossRefGoogle Scholar
  37. 37.
    Hirshberg A, Sheffer N, Barnea O (1999) Computer simulation of hypothermia during “damage control” laparotomy. World J Surg 23:960–965PubMedCrossRefGoogle Scholar
  38. 38.
    Moore EE (1996) Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg 172:405–410PubMedCrossRefGoogle Scholar
  39. 39.
    Kinsky MP, Milner SM, Button B, et al (2000) Resuscitation of severe thermal injury with hypertonic saline dextran: effects on peripheral and visceral edema in sheep. J Trauma 49:844–853PubMedCrossRefGoogle Scholar
  40. 40.
    Cinat ME, Wallace WC, Nastanski F, et al (1999) Improved survival following massive transfusion in patients who have undergone trauma. Arch Surg 134:964–970.PubMedCrossRefGoogle Scholar
  41. 41.
    Neff T, Jungheinrich C, Doelberg M, et al (2001) Advantages of 6% hydroxyethyl starch 130/0.4 (Voluven) at repetitive high dose levels in patients with severe cranio-cerebral trauma. Crit Care 5[Suppl 1]:S53Google Scholar
  42. 42.
    Grauer MT, Baus D, Woessner, et al (2001) Effects on general safety and coagulation after long-term, high-dose volume therapy with 6% hydroxyethyl starch 130/0.4 in patients with acute ischemic stroke. Results of a randomized, placebo controlled, double-blind study. Crit Care 5[Suppl l]:S53–54.Google Scholar
  43. 43.
    Via D, Kauffman C, Anderson D, et al (2001) Effect of hydroxyethyl starch on coagulopathy in a swine model of hemorrhagic shock and resuscitation. J Trauma 50:1076–1082PubMedCrossRefGoogle Scholar
  44. 44.
    Kellum JA, Kramer DJ, Lee K, et al (1997) Release of lactate by the lung in acute lung injury. Chest 111:1301–1305PubMedCrossRefGoogle Scholar
  45. 45.
    Eberhard LW, Morabito DJ, Mathay MA, et al (2000) Initial severity of metabolic acidosis predicts the development of acute lung injury in severely traumatized patients. Crit Care Med 28:125–131PubMedCrossRefGoogle Scholar
  46. 46.
    Rhee P, Wang D, Ruff P, et al (2000) Human neutrophil activation and increased adhesion by various resuscitation fluids. Crit Care Med 28:74–78PubMedCrossRefGoogle Scholar
  47. 47.
    Junger WG, Hoyt DB, Hamreus M, et al (1997) Hypertonic saline activates protein kinases and mitogen-activated protein kinase p38 in T-cells. J Trauma 42:437–443PubMedCrossRefGoogle Scholar
  48. 48.
    Sillett HK, Whicher JT, Trejdosiewicz LK (1998) Effects of resuscitation fluids on T cell immune responses. Br J Anaesth 81:242–243PubMedCrossRefGoogle Scholar
  49. 49.
    Safar P, Tisherman SA, Behringer W, et al (2000) Suspended animation for delayed resuscitation from prolonged cardiac arrest that is unresuscitable by standard cardiopulmonary-cerebral resuscitation. Crit Care Med 28[11 Suppl]:N214–218CrossRefGoogle Scholar
  50. 50.
    Behringer W, Prueckner S, Kentner R, et al (2000) Rapid hypothermic aortic flush can achieve survival without brain damage after 30 minutes cardiac arrest in dogs. Anesthiology 93:1491–1499CrossRefGoogle Scholar
  51. 51.
    McNeil JD, Smith DL, Jenkins DH, et al (2001) Hypotensive resuscitation using a polymerized bovine hemoglobin-based oxygen-carrying solution (HBOC-21) leads to a reversal of anaerobic metabolism. J Trauma 50:1063–1075PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2002

Authors and Affiliations

  • L. J. Kaplan
    • 1
  1. 1.Departments of Surgery and Emergency MedicineMedical College of Pennsylvania-Hahnemann UniversityPhiladelphiaUSA

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