Review article: Feasibility of brachiocephalic vein central venous access for the resuscitation of shocked adult trauma patients: A literature review.

Venous access is a key component of managing haemorrhagic shock. Obtaining intravenous access in trauma patients is challenging due to circulatory collapse in shock. This literature review examines the feasibility of direct puncture and cannulation of the brachiocephalic veins (BCVs) for intravenous access in shocked adult trauma patients. Three literature searches were conducted. OVID Medline was searched for articles on the use of the BCVs for venous access in adults and on the BCVs in shock. A third systematic search of OVID Medline, OVID Embase and Cochrane Library was conducted on the use of the BCVs for access in shocked trauma patients. After full-text review, 18 studies were selected for inclusion for the search on the use of the BCVs for access in adults. No studies met the inclusion criteria for the search on the BCVs in shock and BCV access in shocked trauma patients. The BCVs are currently used for central venous access, haemodialysis and totally implantable venous access devices (TIVADs) in adults. There is a preference for the right BCV (RBCV) over the left as the RBCV is more superficial, straighter, larger, has less anatomical variation and avoids the risk of thoracic duct puncture. The BCVs appear to be stabilised in shock by surrounding bony structures. The BCVs may provide a site for initial, rapid access in trauma resuscitation. Further research is required to determine if the BCVs collapse in shock and if venous access using the BCVs is feasible in a trauma resuscitation setting.

Massive transfusion prediction with inclusion of the pre-hospital Shock Index.

BACKGROUND: Detecting occult bleeding can be challenging and may delay resuscitation. The Shock Index (SI) defined as heart rate divided by systolic blood pressure has attracted attention. Prediction models using combinations of pre-hospital SI (phSI) and the trauma centre SI (tcSI) values may be effective in identifying patients requiring massive blood transfusions (MT). AIM: To explore whether combinations of the phSI and the tcSI augment MT prediction. METHODS: The scores were retrospectively developed using all major trauma patients that presented to The Alfred Hospital between 2006 and 2012. The first PH and TC observations were used. To avoid exclusion of the 'sickest' patients, the SI was imputed to 2 where SBP was missing, but HR was present. We developed 4 models. (i) 'Dichotomised', defined as positive when both phSI and tcSI were ≥1. (ii) 'Formulaic', defined by logistic regression analysis. (iii) 'Combination', defined pragmatically based on the logistic regression. (iv) 'Trending', defined as: tcSI minus phSI. RESULTS: There were 6990 major trauma patients and 360 (5.2%) received MT. There were 1371 cases with either phSI or tcSI missing and were thus excluded from the analysis. The 'Dichotomised' had higher positive predictive value than the tcSI with a further 5 per 100 patients identified. The 'Formulaic' model, defined as: log Odds (MT)=2.16×tcSI+0.89×phSI-5.42, and the 'Combination' model, defined as: phSI×0.5+tcSI, performed equally (AUROC 0.83 versus 0.83, χ(2)=0.86, p=0.35). The 'Formulaic' performed marginally, but statistically significantly, more accurate than the tcSI alone (AUROC 0.83 versus 0.82, χ(2)=6.89, p<0.01). An 'Upward Trending' SI was observed in 1758 patients, revealing a 4.6-fold univariate association with MT (OR 4.55; 95%CI 2.64-7.83), and an AUROC of 0.79 (95%CI 0.74-0.83). The 'Downward Trending' SI was protective against MT (OR 0.44; 95%CI 0.34-0.57). CONCLUSION: The initial pre-hospital SI is associated with MT. However, this relationship did not clinically augment MT decision when combined with the in-hospital SI. The simplicity of the SI makes it a favourable option to explore further. Computer-assisted technology in data capturing, analysis and prognostication presents avenues for further research.

Comparação dos efeitos da ressuscitação com Ringer lactato, solução salina hipertônica e terlipressina sobre a perfusão e oxigenação cerebral em modelo experimental de choque hemorrágico

INTRODUÇÃO: A ressuscitação de baixo volume com solução salina hipertônica (SSH) ou terlipressina pode ser uma alternativa à administração de grandes volumes de cristaloides no tratamento do choque hemorrágico. O objetivo deste estudo foi avaliar os efeitos da HHS e terlipressina sobre a perfusão e oxigenação cerebral e investigar os mecanismos cerebrais envolvidos na microcirculação, função mitocondrial, atividade eletrocortical e vias apoptóticas cerebrais durante choque hemorrágico. MÉTODOS: Animais anestesiados com isofluorano foram submetidos ao choque hemorrágico [grupo Hemo; pressão arterial média (PAM) de 40 mmHg por 30 minutos] e tratados com Ringer lactato (RL) (3RL; 3x volume de sangue removido), terlipressina (grupo Terli; bolus) ou SSH (grupo SSH; 4 mL/kg bolus) e comparados ao grupo Sham. Um modelo porcino (n = 56) foi utilizado para avaliação da pressão de perfusão cerebral (PPC) e de oxigênio tecidual (PbtO2), e da expressão cerebral de marcadores teciduais da regulação de água (aquaporina-4), sódio (cotransportador-1 de Na-K-2Cl), estresse oxidativo (substâncias reativas ao ácido tiobarbitúrico e superóxido dismutase dependente de manganês) e apoptose. Um modelo murino (n = 179) foi utilizado para avaliação da microcirculação (fluorescência de FITC-dextrano) e função mitocondrial (potencial redox e de membrana mitocondrial, utilizando-se a fluorescência de flavoproteínas endógenas e do tetrametilrodamina metil éster, respectivamente) no córtex cerebral, utilizando-se a microscopia confocal in vivo, e para avaliação da atividade eletrocortical cerebral, por meio da monitorização do potencial evocado somatossensorial. No modelo murino foram avaliados três grupos adicionais, constituídos pela associação da terlipressina ao RL (1x, 2x ou 3x volume removido). RESULTADOS: No grupo Hemo porcino, houve uma redução significativa da PPC e PbtO2, associada ao aumento na expressão cerebral de marcadores da regulação do transporte de água e sódio,...

INTRODUCTION: Small-volume resuscitation with hypertonic saline solution (HSS) or terlipressin can be an alternative to the administration of large amounts of crystalloids in haemorrhagic shock. The aim of this study was to evaluate the effects of HSS and terlipressin on cerebral perfusion and oxygenation and investigate the cerebral mechanisms associated with microcirculation, mitochondrial function, electrocortical activity and apoptotic pathways during haemorrhagic shock. METHODS: Isoflurane-anaesthetised animals were submitted to haemorrhagic shock [Haemo group; mean arterial pressure (MAP) of 40 mmHg for 30 minutes] and treated with lactated Ringer's solution (LR) (3LR group; 3x volume bled), terlipressin (Terli group; bolus) or HSS (HSS group; bolus 4 mL/kg) and were compared with a Sham group. A porcine model (n = 56) was used to assess the cerebral perfusion pressure (CPP) and tissue oxygenation (PbtO2) and the expression of tissue markers of water (aquaporin-4), sodium (Na-K-2Cl cotransporter-1), oxidative stress (thiobarbituric acid reactive substances and manganese superoxide dismutase) and apoptosis in cerebral samples. A murine model (n = 179) was used to assess microcirculation (FITC-dextran fluorescence) and mitochondrial function (redox and membrane potential, using the fluorescence of endogenous flavoproteins and tetramethylrhodamine methyl ester, respectively) in the cerebral cortex by using in vivo confocal microscopy, and to assess the electrocortical brain activity by monitoring the somatosensory evoked potential. In the murine model, three additional groups were evaluated, which received terlipressin associated to LR (1x, 2x or 3x blood withdrawn). RESULTS: In the porcine Hemo group, there was a significant decrease in the CPP and PbtO2, which were associated to an increased cerebral expression of markers of water and sodium transport...

Postoperative visual loss due to complicated mediastinal dissection and haemorrhagic shock treatment during cardiac surgery.

We report the case of a patient who underwent third time revision of double heart valve replacement. Mediastinal dissection for right atrium cannulation was complicated by laceration of the superior vena cava; this required temporary rescue clamping of the vessel. The patient suffered complete visual loss related to bilateral retrobulbar haematoma. Acute elevation of superior vena cava pressure due to vascular clamping and administration of large amounts of fluid through the central venous jugular catheter could have caused the postoperative visual loss.

Effects of severe trauma with haemorrhagic shock bypass on serum level of IL-10 / 中国基层医药

Objective Through studying change of serum level of IL-10 in patients of severe trauma with haemorrhagic shock,to investigate effect of severe trauma with haemorrhagic shock bypass on anti-infiammatory reaction in patients.Methods Menbers of experimental group are 43 patients of Severe trauma(ISS scope≥16).43 patients scheduled for attending with haemorrhagic shock are divided into simple severe trauma group(group B)and severe trauma with haemorrhagic shock(group C);and healthy control group(group A)is made up of randomly seleeted 20 healthy people of medical examination.Blood samples for cytokines and organ function were collected from the vetn of menbers of experimental group(B and C)with limosis at the following time:that day of injury,(T1),3th (T2),5th(T3),and 14th(T4)day after injury;blood samples of healthy control group(A)with limosis were collected at that day of examination;serum level of IL-10 was measured by radioimmunoassay.Results In experimental group(B and C),the serum peak level of IL-10 emerged on T3 and then stepped down;the serum peak level of them increased abviously compared with group A(P＜0.05 or P＜0.01).Furthermore,the serum level of them in C group was usually higher than that on the same time in group B.Conclusion It was longer and severer in time and degree that effects of severe trauma with haemorrhagic shock bypass on IL-10 of body compared with that of simple severe trauma.