Uncommon acquired fistulae involving the digestive system: summary of data.

PURPOSE: Most gastrointestinal fistulae commonly occur following surgery. A minority is caused by a myriad of other etiologies and is termed by some as "uncommon fistulae". The aim of this study was to review these fistulae and their treatment. METHODS: A literature review was carried out. Searches were conducted in Pubmed and related references reviewed. RESULTS: Except for Crohn's disease and diverticulitis, "uncommon fistulae" are described in case reports or very small case series. Most of the patients were treated by surgery. CONCLUSIONS: The anatomic features of the fistula and the etiology usually dictate the approach. Most patients will eventually need surgery to resolve this pathology.

Intestinal intussusception in elderly patients.

Intussusception is the most common cause of bowel obstruction in children, but it is a very rare cause of bowel obstruction in the elderly. Diagnosis is based on a high index of suspicion, complete anamnestic recall, physical examination, and imaging modalities. We find abdominal CT scans to be highly sensitive and accurate for making the diagnosis. Treatment of intussusception in adults is always surgical. Segmental bowel resection must be performed. The extent of resection should include any nonviable bowel as well as the leading point of the intussusception. We present a case of an 82-year-old patient with ileo-cecal intussusception, followed by a discussion of the diagnostic and therapeutic options.

Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomized trial.

BACKGROUND: Preoperative mechanical bowel preparation is aimed to reduce the risk of infectious complications, and its utility is a dogma in left-sided large bowel anastomosis. The aim of this study was to specifically assess whether colocolonic and colorectal anastomoses may be safely performed without preoperative mechanical bowel preparation. METHODS: Patients undergoing elective colon and rectal surgery with primary colocolonic or colorectal anastomosis were prospectively randomized into two groups. The "prep" group had mechanical bowel preparation prior to surgery, while the "non-prep" group had surgery without pre-operative mechanical bowel preparation. RESULTS: Two hundred forty-nine patients were included in the study, 120 in the prep group and 129 in the nonprep group. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups. Overall infectious complication rate was 12.5% in the prep group and 13.2% in the non-prep group. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.6%, 4.2%, and 1.6% of patients in the prep group and in 10.0%, 2.3%, and 0.7% of patients in the nonprep group, respectively (p=NS). CONCLUSIONS: These results suggest that elective left-sided anastomosis may be safely performed without mechanical preparation. Multicenter studies to test the reproducibility of these results are required, to support a change in this time-honored practice.

Diagnostic laparoscopy for penetrating injuries in the thoracoabdominal region.

BACKGROUND: The role of laparoscopy in diagnosis of penetrating abdominal injuries is still controversial. In the present investigation diagnostic laparoscopy was studied in penetrating injuries of the thoracoabdominal region. METHODS: Between March 1998 and June 2003, 43 patients with penetrating thoracoabdominal injuries underwent diagnostic laparoscopy at the Rambam Medical Center. There were 41 males and two females; the average age was 30 years (range, 16-54 years). Thirty-one patients had a lower chest injury, eight patients had an upper abdomen and flank injury, and four patients had combined chest and abdomen injuries. In 11 patients intraperitoneal penetration was diagnosed. In 10 patients the procedure was converted to open laparotomy, and one patient with a small laceration of the right diaphragm opposite the liver was observed without laparotomy. RESULTS: The average operating time for the laparoscopy was 25 min (10-45 min), and 85 min (40-175 min) for laparotomy. Patients who underwent laparoscopy were discharged after an average of 1.6 (1-3) days, while those who underwent laparotomy were discharged after an average of 7.6 (2-15) days. CONCLUSIONS: Laparoscopy is a useful diagnostic tool in penetrating injuries of the chest, thoracoabdominal region, and flank. This procedure is particularly reliable in diaphragmatic tears. Laparoscopy should be considered the procedure of choice for the evaluation of penetrating injuries of the lower chest and upper abdomen for diagnosis of peritoneal penetration.

Traumatic abdominal hernia associated with large bowel strangulation: case report and review of the literature.

A rare case of traumatic rupture of the abdominal wall with ventral herniation and strangulation of the right colon is presented. The defect was detected by computed tomography on admission. The patient was operated on 3 days after injury, and irreversible ischaemia of the right colon was found. Right hemicolectomy was performed. The pathogenesis and treatment of this complication is discussed.

Crystalloid and colloid resuscitation of uncontrolled hemorrhagic shock following massive splenic injury.

Using a standardized massive splenic injury (MSI) model of uncontrolled hemorrhagic shock we studied the effect of vigorous crystalloid or colloid fluid resuscitation on the hemodynamic response, and survival in rats. The value of massive fluid infusion in uncontrolled hemorrhagic shock following intra-abdominal solid organ injury is still controversial. The effect of crystalloid and colloid infusion was studied following massive splenic injury. The animals were randomized into six groups: group 1 (n = 8) sham-operated, group 2 (n = 12) MSI untreated, group 3 (n = 10) MSI treated with 41.5 mL/kg Ringer's lactate (large-volume Ringer's lactate, LVRL), group 4 (n = 14) MSI treated with 5 mL/kg 7.5% NaCl (hypertonic saline, HTS), group 5 (n = 10) MSI treated with 7.5 mL/kg hydroxyethyl starch (HES-7.5), and group 6 (n = 11) MSI treated with 15 mL/kg hydroxyethyl starch (HES-15). Following MSI mean arterial pressure (MAP) in untreated group 2 decreased from 109.1 +/- 4.5 to 49.8 +/- 9.6 mmHg (P < 0.001) in 60 min. Mean survival time was 132.1 +/- 18.7 min, and total blood loss was 30.2 +/- 4.1% of blood volume. LVRL infusion resulted in an early rise in MAP from 59.7 +/- 7.3 to 90.0 +/- 11.3 mmHg (P < 0.01), which then rapidly dropped to 11.7 +/- 4.5 mmHg (P < 0.001) after 60 min. The mean survival time was 82.5 +/- 18.2 min (P < 0.01), and total blood loss was 53.7 +/- 2.9% (P < 0.01). Total blood loss following HTS infusion was 32.2 +/- 4.0% and survival time was 127.9 +/- 19.7 min. HES-7.5 infusion only moderately increased bleeding to 44.2 +/- 3.9% (P < 0.05), but mortality remained unchanged. HES-15 infusion resulted in an increase in blood loss to 47.8 +/- 7.1% (0.01), survival time dropped to 100.7 +/- 12.3 min (P < 0.05). Vigorous large volume infusion of Ringer's lactate or HES following MSI resulted in a significant increase in intra-abdominal bleeding and shortened survival time compared to untreated, small volume HTS, or HES-7.5-treated animals. The hemodynamic response to crystalloid or colloid infusion in blunt abdominal trauma is primarily dependent on the severity of injury and the rate of fluid resuscitation.

Overexpression of the high-affinity Fcgamma receptor (CD64) is associated with leukocyte dysfunction in sepsis.

The morbidity and mortality from sepsis and multiple organ dysfunction syndrome (MODS) continues to be high. An increase in FcgammaRI+ (CD64+) monocytes was demonstrated in septic patients, and an association between cell number, their secretory activity, and poor outcome has been described. In the present investigation further characterization of CD64+ leukocytes has been attempted. The study was aimed at examining the phagocytic activity (PA) and reactive oxygen species (ROS) production by monocytes (Mo) and neutrophils (Neu) in sepsis and sepsis-induced acute respiratory distress syndrome (ARDS) related to the pattern of CD64 expression. Twenty-three post-traumatic or post-operative male and female patients with sepsis were enrolled. The control group consisted of 10 healthy volunteers. Arterial blood samples were taken during the septic episode for flow cytometric analysis of surface leukocyte antigens, phagocytosis, and ROS production. CD64 expression on Mo and Neu was markedly increased in septic patients (P = 0.029 and P = 0.0005), and even more in sepsis with ARDS (P = 0.011). In healthy individuals, PA of CD64+ Neu was higher, than of CD64- cells (P = 0.021). In septic patients, decreased PA was detected in CD64+ Mo and Neu (P = 0.013 and P = 0.040, respectively). CD64+ Neu of patients in ARDS exhibited the most prominent PA depression (P = 0.048). ROS production in non-separated Mo and Neu was increased in sepsis (P = 0.026 and P = 0.004, respectively). In healthy individuals CD64+ Neu and stimulated CD64+ Mo demonstrated increased ROS synthesis compared to matched CD64- cells (P = 0.001 and P = 0.042, respectively). Although ROS production by CD64+ leukocytes in sepsis was also increased compared to CD64- cells, significantly less ROS was generated compared to healthy subjects (P = 0.021). In conclusion, overexpression of CD64 on blood Mo and Neu from patients with sepsis and ARDS is associated with depressed PA and decreased oxidative response.

Inverse relation between levels of p27(Kip1) and of its ubiquitin ligase subunit Skp2 in colorectal carcinomas.

BACKGROUND: Previous studies have shown that low levels of p27(Kip1), an inhibitor of G1 cyclin-dependent kinases, are associated with high aggressiveness and poor prognosis in a variety of cancers. Decreased levels of p27 are caused, at least in part, by acceleration of the rate of its ubiquitin-mediated degradation. In cultured cells and cell-free biochemical systems, it has been shown that p27 is targeted for degradation by a ubiquitin ligase complex that contains Skp2 (S-phase kinase-associated protein 2) as the specific substrate-recognizing and rate-limiting subunit. This investigation was undertaken to examine the possible relation between levels of p27 and of its specific ubiquitin ligase subunit Skp2 in human cancers. METHODS: Quick-frozen colorectal tumor samples from 20 patients were homogenized at 0 degrees C in buffer containing a mixture of protease inhibitors. Samples were separated by electrophoresis on sodium dodecyl sulfate-polyacrylamide gels, transferred to nitrocellulose, and probed with highly specific monoclonal antibodies directed against Skp2 and p27. The expression of Skp2 also was examined by immunohistochemistry using formalin fixed, paraffin embedded tissue sections from the same cases. RESULTS: A strongly significant inverse correlation was found between levels of Skp2 and p27 (r = -0.812; P < 0.0001). Thus, decreased levels of p27 were associated with strongly increased levels of Skp2, whereas high levels of p27 coincided with low levels of Skp2. Immunohistochemical examination of Skp2 expression agreed with immunoblot analysis in 89% of cases. CONCLUSIONS: The results are compatible with the notion that increased expression of Skp2 may have a causative role in decreasing the levels of p27 in aggressive colorectal carcinomas.

Influence of hypertonic saline on bacterial translocation in controlled hemorrhagic shock.

Translocation of enteric bacteria has been described in rats following hemorrhagic shock (HS). The aim of the present study was to evaluate the effect of hypertonic saline (HTS) on bacterial translocation (BT) in the setting of controlled HS in rats. The study included 2 arms. Arm I was a qualitative assessment of translocation. Sixty-eight anesthetized animals were studied. The rats were divided into 5 groups. Group I (n = 10) was sham shock controls. In groups II-V, HS was induced by arterial bleeding to mean arterial pressure (MAP) of 35-45 mmHg, which was maintained for 30 min. The animals were then allocated into 4 groups: group II (n = 19) untreated HS; group III (n = 13) normal saline (NS) treated; group IV (n = 13) HTS-treated; and group V (n = 13) HTS and blood treated. Mesenteric lymph nodes, liver, spleen, portal, and systemic blood were sent for culture after 24 h. Translocation occurred if enteric bacteria were cultured from at least one site. Arm II was a quantitative assessment of translocation. Two groups were studied: untreated HS (n = 7) and HTS treated (n = 6). In the qualitative arm, the 24-h mortality in untreated rats (group II) was 31.5% compared to 5.1% in treated animals (groups II-V) (P = 0.01). No BT was detected in control animals (group I). BT after HS was not different between groups II, III, and IV (92.3%, 91.6%, and 100%, respectively). Group V showed fewer translocations than groups II-IV, a difference that was especially significant compared with group IV (P = 0.039). However, BT to distant sites (systemic blood and spleen) was significantly lower in group V than in groups II-IV (P < 0.05). In the quantitative arm, the mortality rate was 16.7% in the untreated group. Although no qualitative significant difference in the translocation rate was found between the two groups (67% in untreated animals vs. 50% in HTS treated), there was significant quantitative difference: in HTS-treated group a significantly lesser bacteria translocated than in untreated animals (0.4 x 10(5) cfu/g vs. 4.2 x 10(5) cfu/g, respectively [P = 0.001]). We concluded that whereas assessed qualitatively, in this model of severe HS in rats, the hemorrhagic insult itself resulted in BT in most animals and treatment with NS, HTS, and blood resulted in reduced early mortality but did not alter significantly the translocation rate. Only the combination of HTS and blood resulted in reduced BT to distant sites. However, quantitative assessment showed that HTS significantly reduced the number of translocating bacteria.

Immune potential of lymph node-derived lymphocytes in uncontrolled hemorrhagic shock.

The state of T cell immunity was evaluated in rats in early (1-4 h) hemorrhagic shock induced by a massive splenic injury. T cell subpopulations from treated and untreated shocked animals were tested by flow cytometry and the results were compared with healthy controls. A fall in CD4+ T lymphocyte and natural killer (NKR-P1+) cell number, marked decline in the T helper (CD4+) to T suppressor (CD8+) ratio, and decrease of interleukin-2 receptor (IL-2R) bearing cells in peripheral blood, mesenteric, and popliteal lymph nodes of rats was found in the early stages of hemorrhagic shock. The same phenotype profile was also revealed in lymphocytes of rats in hemorrhagic shock following massive splenic injury treated with Ringer's lactate. The number of TCRalpha beta and TCR-gamma delta positive cells, as well as the percentage of CD4 and CD8 positive cells in the thymus, was similar in all groups of rats. Culture of lymph node cells taken from rats following hemorrhage in the presence of 100 U/mL hrIL-2 resulted in a marked increase in the number of NKR-PI+ positive cells from 4.2% to 30.5% (P < 0.001). Magnet separated NKR-P1+ fractions lysed the allogeneic fibroblasts in the same manner as IL-2-activated NKR-P1 cells from the control rats. Popliteal lymph node (PLNi) CD8b+ lymphocytes from rats in hemorrhagic shock preinfected into the footpad with cytomegalovirus (CMV) 6 days prior to injury lost their ability to lyse the CMV-infected fibroblasts and protect the monolayer from CMV infection when compared with PLNi cells from control infected rats. The possible mechanisms for the observed cellular dysfunction following hemorrhage are discussed.

Crystalloid or colloid resuscitation of uncontrolled hemorrhagic shock after moderate splenic injury.

Using a standardized moderate splenic injury (MSI) model of uncontrolled hemorrhagic shock, we studied the effect of vigorous crystalloid or colloid fluid resuscitation on the hemodynamic response and survival time in rats. The animals were randomized into 6 groups: group 1 (n = 8) sham-operated, group 2 (n = 10) MSI untreated, group 3 (n = 10) MSI treated with 41.5 mL/kg Ringer's lactate (large-volume Ringer's lactate [LVRL]), group 4 (n = 10) MSI treated with 5 mL/kg 7.5% NaCl (hypertonic saline [HTS]), group 5 (n = 10) MSI treated with 7.5 mL/kg hydroxyethyl starch (HES-7.5), group 6 (n = 10) MSI treated with 15 mL/kg hydroxyethyl starch (HES-15). After MSI, mean arterial pressure (MAP) in group 2 decreased from 105.0+/-5.6 to 64.0+/-12.7 mmHg (P < 0.001) after 60 min. Mean survival time was 157.4+/-28.9 min, and total blood loss was 24.0+/-5.4% of blood volume. LVRL infusion resulted in an early rise in MAP from 75.2+/-8.7 to 96.7+/-9.0 mmHg (P < 0.01), which then rapidly dropped to 43.0+/-9.7 mmHg (P < 0.001) after 60 min. The mean survival time was 140.7+/-22.3 min, and total blood loss was 41.4+/-4.8% (P < 0.05). Total blood loss following HTS infusion was 24.7+/-3.7%, and mean survival time was 177.5+/-18.9 min. HES-7.5 infusion was followed by bleeding of 25.6+/-5.1%, and mean survival time was 181+/-16.1. HES-15 infusion resulted in an increase in blood loss to 48.2+/-7.3% (P < 0.05), and mean survival time of 133.0+/-27.7 min. Large-volume Ringer's lactate (LVRL) or hydroxyethyl starch (HES-15) infusion in uncontrolled hemorrhagic shock after moderate splenic injury resulted in a significant increase in intra-abdominal bleeding, but survival time remained unchanged compared with untreated, small-volume HTS-, or HES-7.5-treated animals. The hemodynamic response to large-volume crystalloid or colloid infusion was similar to moderate large-vessel injury.

The effect of vigorous fluid resuscitation in uncontrolled hemorrhagic shock after massive splenic injury.

OBJECTIVE: Using a standardized massive splenic injury model of uncontrolled hemorrhagic shock, we studied the effect of vigorous fluid resuscitation on the hemodynamic response and survival time in rats. DESIGN: Randomized, controlled study. Duration of follow-up was 4 hrs. SETTING: University research laboratory. SUBJECTS: Adult male Sprague-Dawley rats, weighing 240-430 g. INTERVENTIONS: Standardized massive splenic injury was induced by two transverse incisions in the rat's spleen. The animals were randomized into four groups: group 1 (n = 8) underwent sham operation; in group 2 (n = 15), massive splenic injury was untreated; in group 3 (n = 15), massive splenic injury was treated with 41.5 mL/kg 0.9% sodium chloride (large-volume normal saline); and in group 4 (n = 15), massive splenic injury was treated with 5 mL/kg 7.5% sodium chloride (hypertonic saline). MEASUREMENTS AND MAIN RESULTS: The hemodynamic and metabolic variables in the sham-operated group 1 were stable throughout the experiment. Mean arterial pressure in group 2 decreased from 86.5 +/- 4.0 to 50.3 +/- 6.3 mm Hg (p < .001) in the first 15 mins after massive splenic injury. Mean survival time in group 2 was 127.5 +/- 17.0 mins; total blood loss was 33.8% +/-2.6% of blood volume; and the mortality rate at 1 hr was 13.3%. Bolus infusion of large-volume normal saline after 15 mins resulted in an early increase in mean arterial pressure from 48.6 +/-7.4 to 83.3 +/- 7.2 mm Hg (p < .01); it then rapidly decreased to 24.6 +/- 8.6 mm Hg (p < .001) after 60 mins. The mean survival time (95.3 +/- 16.4 mins) was significantly lower than in group 2 (p < .01); total blood loss (48.0% +/- 4.3%) was significantly higher than in group 2 (p < .01); and mortality rate in the first hour was 33.3% (p < .05). Bolus infusion of hypertonic saline also decreased survival time to 93.3 +/- 20.3 mins (p < .01), but total blood loss was 35.2% +/- 3.0%, which was not significantly different from the blood loss in group 2. The mortality rate in the first hour (60.0%) was significantly higher than in group 2 (p < .005). CONCLUSIONS: Vigorous infusion of normal saline after massive splenic injury resulted in a significant increase in intra-abdominal bleeding and decreased survival time. The hemodynamic response to crystalloid infusion in blunt abdominal trauma is primarily dependent on the severity of injury and the rate of blood loss.

Increasing examiner involvement in an objective structured clinical examination by integrating a structured oral examination.

INTRODUCTION: The role of physician examiners in an objective structured clinical examination (OSCE) is relatively passive. In our institution examiners criticized the passive nature of their role. This study evaluates the reliability and viability of adding a structured oral examination to an OSCE. METHOD: Ten 24-minute stations consisted of three parts. Part I: 12 minutes-patient encounter. Part II: 6 minutes-oral presentation covering findings, differential diagnosis, and management plan. Part III: 6 minutes-structural oral examination (SOE), containing 5 predetermined questions. RESULTS: Over 6 consecutive days, 72 graduates were assessed. Overall average score: 72.02 (SD 5.05); reliability 0.84. Part I of the OSCE average score: 69.2 (SD 7.4); reliability 0.69. Part II oral presentation average score 64 (SD 5.8) reliability 0.87. SOE average score 77.7 (SD 6.3); reliability 0.64. Eighty-nine percent of the examiners indicated satisfaction with the new format. CONCLUSIONS: The SOE was a reliable component of an OSCE and contributed to the overall reliability. Examiners reported a higher degree of satisfaction with the examination.

The effect of nitric oxide synthase inhibition on hypertonic saline treatment of controlled hemorrhagic shock.

The effect of the nitric oxide (NO) donor, L-arginine, and the NO synthase inhibitor, L-NAME on hypertonic saline (HTS) infusion in controlled hemorrhagic shock was studied in anesthetized rats. Hemorrhagic shock was induced by arterial bleeding of 35% of the total blood volume in 90 min. After 110 min, the animals were divided into two groups: in Group A, 5 mL/kg NaCl 7.5% (HTS) was infused. In Group B HTS was not infused. After 135 min the animals in both groups were divided into 4 subgroups: Group 1 (n = 8) was untreated, Group 2 (n = 8) was treated after 135 min with 100 mg/kg L-arginine, in Group 3 (n = 8) 100 mg D-arginine was infused, and in Group 4 (n = 8) 50 mg/kg L-NAME was infused. Arterial bleeding in Group A1 resulted in a fall in mean arterial pressure (MAP) to 43.5 +/- 5 mmHg (p < .001)) in 90 min. A similar fall in MAP was observed in all groups. HTS infusion in Group A1 was followed by an increase in MAP to 82.3 +/- 6 (p < .01)) after 125 min followed by a gradual decrease to 61.5 +/- 8 mmHg (p < .01)) after 4 h. Infusion of L-NAME in Group A4 resulted in an increase in MAP to 87.4 +/- 5 mmHg (p < .01)) that then rapidly dropped to 61.7 +/- 11 (p < .01)) after 4 h. Infusion of L-NAME in Group B4 resulted in an increase in MAP to 96.7 +/- 9 mmHg (p < .001)) which was maintained after 4 h at 92.2 mmHg, and was significantly higher than MAP in Group A4 (p < .01). We concluded that HTS infusion leads to a significant increase in MAP in controlled hemorrhagic shock. NO synthase inhibition by L-NAME in hemorrhagic shock leads to a protracted, significant increase in MAP. Infusion of HTS prevented the significant and sustained rise in MAP induced by L-NAME.

[Laparoscopic unroofing of a giant renal cyst].

Simple cysts of the kidney represent a common abnormality. They may be single or multiple and usually are asymptomatic. However, occasionally they may cause pain and hematuria. Open surgical unroofing eliminates the cyst but may incur postoperative complications and prolonged hospitalization. Laparoscopic unroofing of symptomatic renal cysts has recently been described, but only a few cases have been reported. We present a 24-year-old man with a giant, painful, renal cyst successfully unroofed via transperitoneal laparoscopy.

Hypertonic sodium acetate treatment of hemorrhagic shock in awake rats.

Hypertonic sodium acetate has recently been suggested for treatment of hemorrhagic shock. In the present study, the effectiveness of hypertonic sodium acetate (HA) was studied. In controlled hemorrhagic shock, arterial bleeding was followed by a fall in mean arterial pressure (MAP) to 60 +/- 8 mmHg (p < .001). A similar fall in MAP was observed in all animals. Infusion of hypertonic saline (HTS) led to an increase in MAP to 85 +/- 4 mmHg (p < .005) after 30 min, while infusion of hypertonic sodium acetate (HA) was followed by a rise in MAP to 72 +/- 4 mmHg (p < .05), which was significantly lower than in group HTS-treated animals (p < .05). In uncontrolled hemorrhagic shock, arterial bleeding was followed by a fall in MAP to 86 +/- 7 mmHg (p < .001). A similar response was observed in all animals. Infusion of HTS was followed by a further fall in MAP to 47 +/- 8 mmHg (p < .01) after 60 min. Infusion of HA was followed by a fall in MAP to 51 +/- 4 mmHg (p < .01). In the untreated group, MAP decreased to 63 +/- 5 mmHg, which was significantly higher than the HTS (p < .05)- and HA (p < .05)-treated groups. The mortality rate after 4 h was 50% in the HA-treated (p < .05) and 75% in the HTS-treated (p < .01) groups. It is concluded that, in awake rats in CHS, both HTS and HA led to a rise in MAP but the response to HTS is significantly higher. In UCHS both HTS and HA led to increased bleeding from injured blood vessels, a fall in MAP, and increased mortality.

The effect of heat load and dehydration on hypertonic saline solution treatment of uncontrolled hemorrhagic shock.

Hypertonic saline solution treatment of uncontrolled hemorrhagic shock (UCHS) leads to increased bleeding from injured vessels, fall in arterial blood pressure, and increased mortality. The effect of dehydration induced by either water deprivation or heating on this response was studied in rats. The animals were divided into four groups: group 1 (n = 32), normal rats; group 2 (n = 30), water deprivation for 12 hours; group 3 (n = 30), heating at 37 degrees C for 5 hours; and group 4 (n = 30), heating as in group 3 and water deprivation as in group 2. UCHS was induced in all rats by 20% resection of the animals' tail. The rats were then divided into four treatment subgroups: group a was untreated, group b was treated after 15 minutes with 5 mL/kg NaCl 7.5% hypertonic saline (HTS), group c was treated after 15 minutes with 41.5 mL/kg NaCl 0.9% large volume normal saline (LNS) and group d was treated after 15 minutes with HTS + LNS. Tail resection in group 1a resulted in bleeding of 4.9 +/- 0.3 mL, and fall in mean arterial pressure (MAP) to 50 +/- 3 mm Hg (p < 0.001). Blood loss and fall in hematocrit in groups 2, 3, and 4 was significantly lower than in group 1. The fall in MAP and pulse rate was similar in all four groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversies in shock research: hypertonic resuscitation--pros and cons.

The proper fluid resuscitation of hemorrhagic shock is still controversial. Hypertonic saline has been suggested for prehospital resuscitation of hemorrhagic shock, because of its superior ability to expand blood volume and elevate systemic blood pressure and cardiac output in a small volume and during a short time period. We have defined two types of hemorrhagic shock: controlled hemorrhagic shock (CHS), where the bleeding source is immediately occluded following hemorrhage, and uncontrolled hemorrhagic shock (UCHS), where bleeding is induced by injury to blood vessels that are left unoccluded. It was observed that hypertonic saline (HTS) treatment of controlled hemorrhagic shock leads to an increase in blood pressure and cardiac output, while HTS treatment of UCHS leads to increased bleeding from injured blood vessels, hemodynamic deterioration, and increased mortality. Conversion of UCHS to CHS by tourniquet, military antishock trousers, or surgical hemostasis prevented excessive bleeding and mortality following HTS. Several clinical studies have used hypertonic saline dextran (HSD) or hypertonic saline (HS) for treatment of trauma casualties, but to date no significant improvement in mortality has been demonstrated by either HS or HSD. A more favorable effect but still not statistically significant effect has been demonstrated in patients with a Glasgow Coma Scale of 8 or less. The efficacy of HS has not clearly been established in clinical trials, in all of which HS was used in combination with conventional crystalloid therapy. Further human trials are required to better define the patient population that would benefit most from the prehospital administration of HS.