Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! / Control de Daños Prehospitalario: ¡Para Los Cristaloides, Para La Hipotermia Y…! ¡Para El Sangrado!

Abstract Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

Resumen La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.

Whole blood for blood loss: hemostatic resuscitation in damage control / Sangre total: la nueva alternativa en la resucitación hemostática

Abstract Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

Resumen El choque hemorrágico y sus complicaciones son la principal causa de muerte en los pacientes con trauma. La resucitación en control de daños ha demostrado una disminución en la mortalidad y mejoría en el manejo del paciente. La resucitación hemostática consiste en la recuperación del volumen con hemoderivados como glóbulos rojos, plasma, crioprecipitado y plaquetas, en proporciones de 1:1:1:1. Sin embargo, esta demanda de hemo componentes podría no aplicarse para toda Latinoamérica u otros países de medianos y bajos ingresos. Las principales barreras para la implementación de esta estrategia serían la escasa disponibilidad de bancos de sangre y de hemoderivados insuficientes para contar con un protocolo de transfusión masiva. Una propuesta para superar estas barreras es el uso de sangre total fresca fría para la resucitación hemostática de los pacientes exsanguinados. Ecuador ha sido pionero en la implementación de esta estrategia con una experiencia ya de seis años, en que han demostrado que la sangre total tiene ventajas sobre la terapia de hemo componentes incluyendo, pero no limitando, la trasfusión de sangre con una razón fisiológica de componentes, fácil transporte y transfusión, menor volumen de anticoagulantes y aditivos trasfundidos al paciente, y menor exposición a donantes. La sangre total es una herramienta con un potencial reemergente que puede ser implementado en centros de trauma civil con óptimos resultados y menor demanda técnica.

Rotational thromboelastometry assessment of ballanced crystalloid, hydroxyethyl starch and gelatin effects on coagulation: a randomized trial / Tromboelastometria rotacional na avaliação dos efeitos de cristaloides balanceados, hidroxietilamido e gelatina na coagulação: estudo randômico

Abstract Background and objectives Modern crystalloid and colloid solutions are balanced solutions which are increasingly used in perioperative period. However, studies investigating their negative effect on whole blood coagulation are missing, and vivid debate is going on about which solution has the minimal coagulopathy effect. The aim of our study was to assess the effect of modern fluid solutions on whole blood coagulation using rotational thromboelastometry. Methods Blood samples were obtained from 30 patients during knee arthroscopy before and after administration of 500 mL of crystalloid, Hydroxyethyl Starch and gelatin according to the randomization. Rotational thromboelastometry (Extem, Intem and Fibtem tests) was used to assess negative effect of fluid solutions on whole blood coagulation. Results In Extem test, the initiation phase of fibrin clot formation represented by CT parameter was not influenced by any fluid solution (p > 0.05). The speed of clot formation represented by CFT and α angle was impaired by Hydroxyethyl Starch and gelatin but not by crystalloids (p < 0.05). The strength of formatted coagulum represented by MCF parameter was impaired both in Extem and Fibtem test by HES and in Fibtem also by crystalloids (p < 0.05). Intem test was not negatively influenced by any crystalloid or colloid solution in any parameter (p > 0.05). Conclusion Extem test appears to be sensitive to coagulopathy effect of modern colloids and crystalloids. Hydroxyethyl starch has the most obvious negative effect on clot formation followed by gelatin and finally by crystalloids. Intem test seems to be insensitive to adverse effect of modern colloids and crystalloids.

Resumo Justificativa e objetivos Os cristaloides e coloides modernos são soluções balanceadas e cada vez mais utilizadas no período perioperatório. No entanto, não há estudos que avaliem seu efeito negativo na coagulação do sangue total e o intenso debate sobre a solução que cause um efeito mínimo na coagulopatia permanece. O objetivo de nosso estudo foi avaliar o efeito das soluções líquidas modernas na coagulação do sangue total com o uso da tromboelastometria rotacional. Métodos De acordo com a randomização, amostras de sangue foram colhidas de 30 pacientes durante a artroscopia de joelho, antes e após a administração de 500 mL de cristaloides, hidroxietilamido e gelatina. A tromboelastometria rotacional (testes Extem, Intem e Fibtem) foi utilizada para avaliar o efeito negativo das soluções líquidas na coagulação do sangue total. Resultados No teste Extem, a fase de iniciação da formação de coágulos de fibrina representada pelo parâmetro CT não foi influenciada por qualquer solução líquida (p > 0,05). A velocidade da formação de coágulos representada pelo CFT e pelo ângulo α foi prejudicada pelo hidroxietilamido e pela gelatina, mas não pelos cristaloides (p < 0,05). A força do coágulo formatado representado pelo parâmetro MCF foi prejudicada tanto no teste Extem quanto no teste Fibtem pelo HES e no teste Fibtem também pelos cristaloides (p < 0,05). O teste Intem não foi influenciado negativamente por nenhuma solução cristaloide ou coloide em nenhum parâmetro (p > 0,05). Conclusão O teste Extem parece ser sensível ao efeito de coagulopatia dos coloides e cristaloides modernos. O hidroxietilamido apresentou o efeito negativo mais óbvio na formação do coágulo, seguido pela gelatina e finalmente pelos cristaloides. O teste Intem parece ser insensível ao efeito adverso dos coloides e cristaloides modernos.

The effects of crystalloid warming on maternal body temperature and fetal outcomes: a randomized controlled trial / Os efeitos do aquecimento de cristaloides sobre a temperatura corporal materna e nas condições fetais: ensaio clínico randômico

Abstract Background and objectives: Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia. Methods: In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37 °C. Spinal anesthesia was performed at L3-L4 interspace with 10 mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section. Results: There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p = 0.004). Core temperature was 36.8 ± 0.5 °C at baseline and decreased to 36.3 ± 0.5 °C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9 ± 0.4 °C and decreased to 35.8 ± 0.7 °C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups. Conclusions: Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

Resumo Justificativa e objetivos: A hipotermia ocorre em cerca de 60% dos pacientes sob anestesia e geralmente não é tratada adequadamente durante procedimentos cirúrgicos de curta duração. A hipotermia está associada a desfechos clínicos adversos. O presente estudo teve como objetivo avaliar os efeitos do aquecimento de cristaloides nas condições maternas e fetais em pacientes submetidas à cesariana eletiva com raquianestesia. Métodos: Neste estudo prospectivo, randômico e controlado, 60 parturientes agendadas para cesárea eletiva com raquianestesia foram distribuídas aleatoriamente para receber cristaloides à temperatura ambiente ou aquecidos a 37 °C. A raquianestesia foi realizada no interespaço L3-L4 com 10 mg de bupivacaína hiperbárica sem adição de opioides. Temperatura central, tremores e parâmetros hemodinâmicos foram medidos a cada minuto até o décimo minuto e em intervalos de 5 min até o fim da operação. O desfecho primário foi a temperatura central materna ao final da cesárea. Resultados: Não houve diferença nas mensurações basais da temperatura timpânica, mas a diferença foi significativa no fim da operação (p = 0,004). A temperatura central foi de 36,8 ± 0,5 °C na fase basal e diminuiu para 36,3 ± 0,5 °C no grupo com aquecimento isotérmico de cristaloides e a temperatura basal timpânica foi de 36,9 ± 0,4 °C e diminuiu para 35,8 ± 0,7 °C no grupo sem aquecimento das soluções no fim da operação. Tremores foram observados em 43,3% no grupo controle. Alterações nos parâmetros hemodinâmicos e dados demográficos não foram significantes entre os grupos. Conclusões: O aquecimento isotérmico de cristaloides previne a redução da temperatura central durante a cesariana com raquianestesia em parturientes a termo. Os escores de Apgar para os fetos no primeiro e quinto minutos são maiores com o aquecimento isotérmico.

Uso de la matriz hemostática Floseal® en el control de la hemorragia obstétrica: estudio de seguimiento y costos asociados con el tratamiento / Use of Floseal® hemostatic matrix in the management of obstetric hemorrhage: A follow-up and costs related to treatment

Resumen OBJETIVO Evaluar cómo se atendieron las pacientes con hemorragia obstétrica, qué recursos se utilizaron y los costos directos relacionados con el tratamiento de pacientes con placenta previa, con o sin placenta acreta, en quienes se indicó Floseal® como parte de las medidas de control e inhibición de la hemorragia en comparación con quienes solo recibieron los cuidados convencionales. MATERIALES Y MÉTODOS Estudio retrospectivo, observacional y comparativo de los expedientes clínicos de pacientes adultas con más de 20 semanas de gestación y placenta previa tratadas entre septiembre y noviembre del 2012 en la Unidad Médica de Alta Especialidad 23 en Monterrey, México. Los resultados clínicos y costos se compararon con pruebas paramétricas y no paramétricas. RESULTADOS Se analizaron 29 expedientes (15: Floseal® coadyuvante, 14: solo con tratamiento convencional). El grupo tratado con Floseal® tuvo menos reintervenciones (0 vs 57.1%, p 0.0010), días de estancia hospitalaria [2(2-4) vs 6(4-11), p 0.0048] y cuidados intensivos (2.4 ± 1.5 vs 4.5 ± 2.1, p 0.0048). El costo promedio por remuestreo fue de 109,172.00 pesos mexicanos (IC95%: 80,153.10-139,073.71 pesos) para Floseal® vs 224,289.00 pesos mexicanos (IC95%: 181,881.48-269,061.23 pesos) para el tratamiento convencional a expensas de un número de piezas mayor de Tisseel®, crioprecipitados, cristaloides y retiro quirúrgico de compresas. CONCLUSIONES El uso coadyuvante de Floseal® se asoció con menor número de reintervenciones, días de estancia hospitalaria y atención en cuidados intensivos. Se registraron menores costos promedio y total asociados con la atención. Para corroborar estos resultados en población mexicana se requieren análisis de largo seguimiento y con muestras más grandes.

Abstract OBJECTIVE To evaluate the clinical outcomes and direct costs related to treatment of placenta previa with Floseal® hemostatic matrix as part of the treatment of obstetric hemorrhage in comparison with conventional management only. METHODS Clinical records of patients with hemorrhagic hemorrhage, with more than 20 weeks of pregnancy and placenta previa were reviewed, all patients were adults and treated within September and November of 2012 in the "Unidad Médica de Alta Especialidad 23" of the Mexican Institute of Social Security, Monterrey, México. Costs where estimated using the Diario Oficial de la Federación 2013) and a resampling was performed. Clinical and costs outcomes where compared with parametric and non-parametric tests. RESULTS 29 clinical records (15: Adjuvant Floseal®, 14: conventional treatment only). Floseal® group resulted in less re-interventions (0% vs 57.1%, p 0.0010), days of hospital stay [2(2-4) vs 6(4-11), p 0.0048] and days in the intensive care unit (2.4 ± 1.5 vs 4.5 ± 2.1, p 0.0048). Average cost by resampling was $109,172.00 [CI95% (80,153.10-139,073.71 mexican pesos)] for Floseal® vs 224,289.00 mexican pesos [IC95% (181,881.48-269,061.23)] for conventional treatment at the expense greater number of pieces of Tisseel®, cryoprecipitate, crystalloids and surgical removal of compresses. CONCLUSIONS The adjuvant use of Floseal® was associated with fewer re-interventions, days of hospital stay and intensive care. Lower average and total costs associated with treatment were also estimated. Future long-term analyzes and larger sample sizes are necessary to corroborate these results in the Mexican population.

Rehidratación en el paciente pediátrico / Rehydration in pediatric patients / Rehidratação em pacientes pediátricos

La deshidratación en el paciente pediátrico es una de las causas de morbimortalidad más importantes en países en vía de desarrollo; por tanto, es imprescindible el correcto manejo de esta patología con el fin de disminuir los desenlaces fatales y prevenibles de la enfermedad. Se realizó una revisión de la literatura con respecto a la fisiología, la fisiopatología, la clínica, el mecanismo de acción, las indicaciones y las contraindicaciones de las sales de rehidratación oral y las soluciones de administración endovenosa, con el fin de brindar ciertas pautas y recomendaciones basadas en la evidencia actual, a todos los profesionales de la salud, que a diario enfrentan este tipo de patología. La investigación demostró que las sales de rehidratación oral siguen siendo el Gold Estándar en el tratamiento de la deshidratación leve a moderada en pacientes con indicaciones de uso y que las soluciones de administración endovenosa son de vital apoyo en aquel grupo de pacientes con deshidratación grave con intolerancia a la vía oral, shock, íleo paralitico, ciertas patologías quirúrgicas y con contraindicaciones de terapia con sales de rehidratación oral.

Dehydration in pediatric patients is one of the most common causes of mobility and mortality in developing countries; therefore, the right management of this disease is essential in order to reduce fatal and preventable disease outcomes. A review of the literature was made with respect to the physiology, pathophysiology, clinical manifestations, mechanism of action, indications and contraindications of oral rehydration salts and intravenous solutions, in order to provide some recommendations based on current evidence, to all physicians, who daily work on this kind of pathology. The investigation showed that ORS remains the Gold Standard in the treatment of mild to moderate dehydration in patients with indications and intravenous solutions, are of vital support in the group of patients with severe dehydration, oral intolerant, shock, paralytic ileus, certain surgical pathologies and therapy contraindications ORS.

A desidratação em pacientes pediátricos é uma das causas mais comuns de mobilidade e mortalidade nos países em desenvolvimento; Portanto, o manejo correto desta doença é essencial para reduzir os resultados fatais e evitáveis da doença. Realizou-se revisão da literatura em relação à fisiologia, fisiopatologia, manifestações clínicas, mecanismo de ação, indicações e contra-indicações dos sais de reidratação oral e soluções intravenosas, a fim de fornecer algumas recomendações baseadas em evidências atuais a todos os médicos, que diariamente Trabalho sobre esse tipo de patologia. A investigação mostrou que a SRO permanece como padrão-ouro no tratamento da desidratação leve a moderada em pacientes com indicações e soluções intravenosas, são de suporte vital no grupo de pacientes com desidratação grave, intolerância oral, choque, íleo paralítico, certas patologias cirúrgicas e Terapia contra-indicações ORS.

Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions / Coloides versus cristaloides em fluidoterapia guiada por objetivos, revisão sistemática e metanálise. Demasiadamente cedo ou demasiadamente tarde para obter conclusões / Coloides versus cristaloides en fluidoterapia guiada por objetivos, revisión sistemática y metaanálisis. Demasiado pronto o demasiado tarde para obtener conclusiones

Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality.

Foram feitos múltiplos ensaios clínicos em fluidoterapia guiada por objetivos (FGO), muitos deles com o uso de coloides para aprimoramento da pré-carga. Após a decisão da Agência Europeia de Medicamentos, existe ainda controvérsia sobre seu uso, seus benefícios e sua possível contribuição para a falência renal. O objetivo desta revisão sistemática e metanálise é comparar o uso de coloides de última geração, derivados de milho, com cristaloides em FGO para determinar as complicações e a mortalidade associadas.

Se han realizado múltiples ensayos clínicos en fluidoterapia guiada por objetivos (FGO), muchos de ellos con el uso de coloides para la optimización de la precarga. Tras la decisión de la Agencia Europea del Medicamento, existe cierta controversia en cuanto a su utilización, beneficios y su posible contribución al fallo renal. El objetivo de esta revisión sistemática y metaanálisis es comparar el uso de coloides de última generación, derivados del maíz, con cristaloides en FGO para determinar las complicaciones y la mortalidad asociadas.

Evidencia actual sobre el uso de soluciones coloides versus cristaloides durante la reanimación del paciente con shock / Current evidence onthe use of solutions colloids versus crystalloids during the reanimation patient-with shock

La administración de fluidos intravenosos, es uno de los pilares de la reanimación del paciente en shock y su beneficio es mayor cuanto antes se inicie. Los fluidos más utilizados para tal objeto son las soluciones cristaloides (solución salina y Ringer Lactato) y los coloides (albumina, gel, dextrán y almidones). Estudios fisiológicos y clínicos han demostrado que los coloides y los cristaloides tienen diferentes efectos y perfiles de seguridad. Por otra parte, ambos tipos de fluidos administrados en exceso o a destiempo pueden tener efectos perjudiciales. Estudios clínicos recientes parecen coincidir que, en general, los coloides no ofrecen mayor beneficio clínico que los cristaloides y se asocian a mayor tasa de eventos adversos. Por tanto, el presente artículo pretende describir las ventajas y limitaciones de los tipos de soluciones que se utilizan para la reanimación de los pacientes críticos en base a literatura más reciente.

The administration of intravenous fluids, is a mainstay of patient resuscitation in shock and your benefit is greater the earlier it starts. The fluids commonly used for this purpose are crystalloid solutions (saline and Ringer Lactate) and colloids (albumin, gel, dextran and starch). Physiological and clinical studies have shown that colloids and crystalloids have different effects and safety profiles. Moreover, both ty-pes of fluids administered in excess or untimely can have detrimental effects. Recent clinical studies seem to agree that, in general, colloids offer no greater clinical benefit than crystalloids and are associated with increased rate of adverse events. Therefore, this article aims to describe the advantages and limitations of the types of solutions used for resuscitation of critically ill patients based on recent literature.

Reposición de volumen en el politraumatizado / Volume reposition in trauma

El manejo actual de los pacientes traumatizados, que constituyen un desafío, se realiza en varias fases, en función de las características de las lesiones y la capacidad de los equipos de rescate y reanimación. La hemorragia masiva constituye la principal causa de muerte en estos pacientes y la reposición de volumen debe enfocarse con una variedad de productos, comenzando con los cristaloides y en función de la evolución y respuesta a estos, la utilización de coloides y finalmente los Hemoderivados. Cada uno de estos productos presenta ventajas y problemas, y continúa siendo el juicio clínico el principal criterio en su utilización ya que, en el contexto de esta situación de emergencia, el laboratorio suele ir detrás de la realidad. El control de la hemorragia es uno de los principales objetivos a lograr, sin el cual ninguna otra medida médica evitará la muerte de estos pacientes.

Trauma patients represent a challenge for health providers. Clinical management has to be provided accordignly to their medical conditions, injuries and also to the level of experience of the emergency room team. Because massive bleeding is the main cause of death in this group of patients, volume reposition has to be one of the most important goals in order to improve their survival outcome. This is the reason why it is important in health providers a solid knowledge of volume replacement algorithms in trauma cases. Volume reposition algorithms usually recommend starting with cristaloid solutions, following with coloids and finally hemoderivatives. All these products have their own advantages but also disadvantages, being the clinical judgement the most important tool in order to know when and how to use them. In the trauma field, the laboratory tests are often not available or their results are too slow to wait for. We still need to set in the future the advantages of oxygen carrying substances (or substitutes) to improve survival rates in the field of trauma.

Revisión sistemática sobre la eficacia de los fluidos coloides y cristaloides en la reposición inicial del volumen intravascular en el tratamiento del dengue hemorrágico con shock / Systematic review: efficacy of colloids versus crystalloids for initial fluid resuscitation in dengue haemorrhagic shock

OBJETIVO: comparar la efectividad de las soluciones coloides versus las cristaloides en el tratamiento inicial del shock por dengue hemorrágico. MÉTODO: La búsqueda bibliográfica fue realizada en las bases Medline, Lilacs, Biblioteca Cochrane y en texto libre con el motor Google. Solamente tres de los 14 estudios identificados y potencialmente elegibles cumplían con los criterios de selección preestablecidos. En total, incluyeron 792 pacientes menores de 15 años de edad con shock por dengue hemorrágico. La mortalidad en las primeras 24 horas, la recurrencia del shock y el tiempo insumido para la recuperación de la presión de pulso, fueron considerados los resultados principales para la evaluación. RESULTADOS: Sólo un estudio refiere una muerte sobre 512 pacientes. La recurrencia del shock ocurrió en el 23,7 por ciento de aquellos inicialmente tratados con coloides y en el 25,5 por ciento de los tratados con cristaloides (RR 0,93; IC95 por ciento 0,63 a 1,38). El tiempo de la recuperación del pulso fue medido en un solo estudio, mostrando un beneficio marginal para los tratados con coloides (RR 0,40;IC95 por ciento 0,16 a 0,99). Las reacciones alérgicas severas fueron más frecuentes en los tratados con coloides (RR 5,43; IC95 por ciento 0,33 a89,13). El precio de las soluciones coloides disponibles en plaza fue hasta 90 veces mayor que el de las soluciones cristaloides. CONCLUSIONES: En la presente revisión sistemática no se identificaron razones clínicamente relevantes y sustentadas por evidencia que aconsejen recomendar el uso de soluciones coloides en el tratamiento inicial del shock por dengue hemorrágico.

OBJECTIVE: The aim of this systematic review was to compare the effectiveness of colloids and crystalloids solutions as initial treatment of dengue hemorrhagic shock. METHOD: A comprehensive bibliographic search was carried out through Medline, Lilacs, Cochrane Library andusing search motor Google. Only three out of the 14 studies initially identified fulfilled the inclusion criteria. In total, they included 792 patients less than 15 years old with dengue hemorrhagic shock. Mortality during first 24 hours, shock recurrence and time to recovery of hemodynamic variables were used as main outcomes to assess effectiveness among solutions. RESULTS: Only one patient death out of 512 during the first 24 hours was reported by a single study. Shock recurrence occurred in 23.7 percent of those initially treated with colloids and in 25.5 percent in those treated with crystalloids (RR0.93, CI95 percent 0.63 to 1.38). Pulse pressure recovery after 1 hour was measured in only one study, showing a marginal benefit from colloids solutions (RR 0.40; CI95 percent 0.16 to 0.99).Severe allergic reactions were more frequent in colloids group (RR 5.43; CI95 percent 0.33 to 89.13). Otherwise, colloids solutions price is up to 90 times higher than crystalloids. CONCLUSIONS: This review did not identify any clinically relevant and evidence supported reason to prescribe colloids solutions instead crystalloids solutions in the initial treatment of dengue hemorrhagic shock.

Hemogasometria em cães com desidratação experimental tratados com soluções eletrolíticas comerciais administradas por via intravenosa / Blood gas analysis in dogs with experimental dehidration treated with commercial electrolytes solutions by intravenous route

No presente estudo, foram comparados os efeitos da administração intravenosa de três soluções eletrolíticas comerciais sobre o equilíbrio ácido-base em cães desidratados experimentalmente por restrição hídrica e poliúria. Os animais foram aleatoriamente distribuídos em três grupos e tratados com três diferentes soluções eletrolíticas comerciais durante 12 horas: Ringer com lactato de sódio (RL), Ringer simples (RS) e Glicofisiológico (GF). Entre os tratamentos testados, a fluidoterapia intravenosa com solução de Ringer com lactato de sódio (RL) foi o tratamento que apresentou efeito alcalinizante, sinalizado por pequeno aumento nos valores do pH(a), cHCO3(aP), ctCO2(aP) e cBase(a), podendo ser utilizada no tratamento de animais com acidose metabólica de intensidade discreta a moderada. As soluções Ringer simples (RS) e glicofisiológica (GF) determinaram discreta diminuição na concentração de base titulável do sangue arterial (cBase), demonstrando efeito acidificante, o que as tornam uma opção para tratar cães com alcalose metabólica.

Three commercial intravenous electrolyte solutions were compared as for their effects on the blood acid-base status in dogs experimentally dehydrated by withholding water and inducing polyuria. Animals were randomly divided into three groups which were rehydrated with the following commercial electrolyte solutions during 12 hours: Lactate Ringerïs solution (RL), Ringerïs solution (RS) and a normal saline solution (0.9 percent sodium chloride) containing 5 percent dextrose (GF). The RLïs intravenous fluid therapy resulted in an alkalinizing effect demonstrated by a mild increase in arterial blood pH, ctCO2, bicarbonate (cHCO-3), and arterial blood base concentration (cBase) and, thus, can be used in animals exhibiting mild to moderate metabolic acidosis. In contrast, the RS and GF therapies led to a mild decrease in the concentration of arterial blood tritiable base (cBase) inducing an acidifying effect, which make them an option to treat dogs with metabolic alkalosis.

Manejo de líquidos en el paciente quirúrgico / Fluid management in surgical patients

La administración de líquidos y la resucitación hacen parte integral del manejo del paciente quirúrgico y la escogencia del líquido en cualquier situación es motivo de debate. El entender la distribución corporal de los líquidos por compartimentos permite al clínico evaluar los déficits individuales en el paciente críticamente enfermo o en el quirúrgico y reemplazar las pérdidas con el fluido adecuado. La fisiología está bien entendida, pero los patrones de déficits y la distribución de líquidos son aún motivo de controversia en algunos pacientes críticos, lo que ha generado algún debate en cuanto al uso apropiado de cristaloides o coloides en dichos pacientes. Se presenta seguidamente una revisión y guía sobre el manejo perioperatorio del paciente quirúrgico adulto y pediátrico, incluyendo el reemplazo de líquidos antes, durante y después de la cirugía.

Fluid administration and resuscitation are an integral part in the management of surgical patients and the choice of fluids in any given situation is a topic of much debate. Understanding body fluid distribution by compartments enables the clinician to assess an individual´s deficits during critical illness or surgery, and to replace losses with the appropriate resuscitative fluid. Normal physiology is well understood, but patterns of fluid deficits and distributions remain controversial in some critically ill patients. This has resulted in some controversy concerning appropriate use of crystalloids and colloids in critical illness. We present a review and guide to perioperative fluid management of adult and pediatric surgical patients, including preoperative, intra and postoperative replacement.