Journal of Indonesian Orthopaedic, Volume 40, Number 2, August 2012 17

Small Volume Resuscitation in Hemorrhagic Shock:

Historical and Scientific Background

Phedy,1 Benny Philippi2

1
Departement of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Indonesia
2
Divison of Digestive Surgery, Department of Surgery, Cipto Mangunkusumo Hospital-Faculty of Medicine, Universitas Indo-
nesia

ABSTRACT

Exsanguination is the primary cause of death in trauma. The mortality can be prevented if bleeding can be stopped
and blood loss can be replaced with fluid. Fluid resuscitation has been proven to improve tissue perfusion and reverse
the cellular injury and swelling in state of hemorrhage. Fluid resuscitation can also depress the cytokines that could
lead to multiple organ failure in hemorrhagic shock. The method of fluid resuscitation widely used nowadays refers
to guideline by American College of Surgeon. Despite its wide application, some studies reported the guideline may
be harmful and addressed the lack of its scientific basis. These studies introduced another strategy called small vol-
ume fluid resuscitation. Although studies were limited to animal model and some small clinical trials, they showed
promising result for small volume fluid resuscitation. Small volume fluid resuscitation could reduce the additional
blood loss due to continued bleeding or re-bleeding and lower mortality rate. Small volume fluid is an appropriate
option in resuscitating patients especially those with uncontrolled hemorrhage.

Key words: fluid resuscitation, small volume resuscitation, controlled resuscitation, permissive hypotension

Corresponding author:
Phedy, MD
Jl. Venice 5 No. 38
Pantai Indah Kapuk
Phone: 08561961498
Email: [email protected]
Small volume fluid resuscitation 18

Resusitasi Cairan Volume Kecil pada Syok Hemoragic:

Latar Belakang Sejarah dan Ilmiah

ABSTRAK

Pendarahan merupakan penyebab kematian utama pada trauma. Kematian dapat dicegah bila pendarahan dapat di-
hentikan dan kehilangan darah dapat digantikan dengan cairan. Resusitasi cairan terbukti dapat memperbaiki perfusi
jaringan dan mengembalikan kerusakan serta pembengkakan sel yang terjadi akibat pendarahan. Resusitasi cairan
juga dapat menekan kadar sitokin yang dapat menyebabkan gagal organ multipel pada syok hemoragik. Metode re-
susitasi cairan yang dilakukan selama ini mengacu pada pedoman resusitasi American College of Surgeon. Meskipun
telah luas diaplikasikan, beberapa penelitian melaporkan adanya bahaya dan mempertanyakan dasar ilmiah pedoman
resusitasi tersebut. Penelitian tersebut memperkenalkan pilihan resusitasi lain yang disebut resusitasi cairan volume
kecil. Resusitasi cairan volume kecil mengurangi risiko pendarahan lebih lanjut akibat pendarahan yang berkelanju-
tan atau pendarahan ulang dan menekan angka kematian. Oleh karena itu, resusitasi cairan volume kecil merupakan
pilihan yang lebih tepat untuk meresusitasi pasien terutama pada pasien yang perdarahannya sulit dikendalikan.

Kata kunci: resusitasi cairan, resusitasi volume kecil, resusitasi terkontrol, hipotensi permisif

Introduction and scientific background of small volume fluid resusci-

Trauma remains major health problems both in high and tation.
low to middle-income countries. It is the most common
History of fluid resuscitation
cause of death in high-income countries and second most
While fluid resuscitation has been introduced since 19th
common cause of death in low to middle income coun-
century, it has not gained popularity until the end the first
tries only after infection.1 It is estimated that 16 000 peo-
world war. During the world war, it was only known that
ple die due to trauma per day.1 Among them, 30-50% are
delayed in definitive surgery to stop bleeding would in-
the results of hemorrhagic shock.2
crease the risk of dead.9
Fluid resuscitation is the mainstay of therapy for
Year 1918 was the start of historical milestone for flu-
hemorrhagic shock.3 It improves tissue perfusion, and re-
id resuscitation. In that year, Walter Canon reported that
stores cellular injury and edema in hemorrhagic shock.
in order to treat shock, procedures to restore normal and
It also depresses level of multi organ failure causing cy-
stable blood flow were obligatory.10 Those procedures
tokines.4
included rapid bleeding control and blood loss replace-
American College of Surgeon published a guideline
ment.10 In the same year, he reported that blood replace-
in fluid resuscitation.3 This guideline has been accepted
ment before adequate bleeding control would deteriorate
worldwide, including in Indonesia. However, some au-
bleeding. He recommended that resuscitation should not
thors now questioned the scientific background of the
exceed 70 to 80 millimeter mercury of systolic blood
guideline and reported the jeopardy in applying it.5-8
pressure if the bleeding could not be controlled.11
As an alternative, they suggested resuscitation using
During the second world war (1939-1945), Beecher
small volume of fluid. This article reviews the historical
applied the resuscitation principle of Canon.11 He ob-
Journal of Indonesian Orthopaedic, Volume 40, Number 2, August 2012 19

served that using the principle, none of his patients died of resuscitation. The mortality rate was 100 % in resusci-
due to uncontrolled bleeding. He used plasma or serum tation group compared to zero percent in group who did
to replace the blood loss and considered saline or glucose not received resuscitation.
to be inappropriate fluid replacement due to their rapid The report of Bickell motivated other authors to
escape from intra vascular.12 question the rationality of large volume crystalloid re-
In 1960 however, the resuscitation principle of Can- placement. They found that lack of randomized clinical
on was abandoned. Studies in animal found that lowest trial were evident to support the resuscitation concept.
mortality in hemorrhagic shock was achieved using large Moreover, animal model used in the studies that sup-
volume of crystalloid, equal to three times the volume of port large volume resuscitation was not representative.
blood loss.12 It should be noticed that hemorrhagic shock In the model, rapid definitive bleeding control could be
in those animal models were achieved by introduction of achieved by closing the catheter.13 The model differs sig-
intravenous catheters, after which were closed by stop- nificantly from actual patient whose bleeding often can-
pers to prevent further bleeding.13 not be adequately controlled.13
The concept of large volume crystalloid replacement Studies have focuses to find more representative
was adopted during Vietnam war (1959-1975). It suc- model in which the hemorrhage is difficult to control
ceeded in lowering the incidence of acute kidney failure such as large vessel injury or abdominal trauma.6-8 Stern,
although the incidence of pulmonary shock, an entity et al.7 introduced aortic injury in pig and found that more
known later as acute respiratory distress syndrome, ex- bleeding and higher mortality resulted in group resusci-
ploded. Although the pulmonary shock was first believed tated to mean artery of 80 millimeter mercury compared
to occur due to excessive crystalloid replacement, it was to group resuscitated to 40 and 60 millimeter of mercu-
not proven in meta-analyses.12,14,15 Thus, the concept of ry. Sindilinger, et al.6 used resection of tail in rodent to
large volume crystalloid replacement resumed. achieve representative model and found more bleeding
The guideline of fluid resuscitation by American occurred in group treated with 80 mL/kg body weight
College of Surgeon is partly, if not merely, based on of fluid compared to group treated with 40mL/kg body
the concept of fluid resuscitation using crystalloid. It weight. Larger volume will cause re-bleeding due to
recommends that as much as two liter of crystalloid dissipation of clot and dilution of clotting factors.11,17-19
should be given using two large bore intravenous cath- Sonden, et al., cited from Holcomp,11 showed that re-
eters rapidly.16 Additional fluid could be given according bleeding would occurred at 94 ± 3 millimeter mercury
to hemodynamic responses until normal blood pressure of systolic blood pressure, irrespective of size of defect
is achieved. Transient response patients in hemorrhagic in aorta.
shock class II and III, and unresponsive patients in hem- In addition to more bleeding, studies have proven that
orrhagic shock class III and IV usually necessitate ad- aggressive fluid resuscitation will lower the core temper-
ditional fluid.16 ature and cause visceral edema, abdominal compartment
syndrome, intracranial hypertension, extravascular fluid
Scientific background of small volume fluid resuscita-
accumulation in the lung, as well as increasing mortal-
tion
ity.11,17-19
In 1991, Bickell5 reported that poor effect would be
On the other hand, Ley, et al.20 in their prospective
resulted if traditional fluid resuscitation was applied in
cohort of 3137 patients found that fluid volumes of 1.5
cases in which the hemorrhage was not massive. Volume
liter or more were significantly associated with mortal-
as much as three times of blood loss would result in more
ity in both elderly and nonelderly patients. In patients
prominent bleeding and higher mortality rate in first hour
Small volume fluid resuscitation 20

receiving fluid up to one liter, no significant increase in restore circulation with minimal elevation of blood pres-
mortality was found. Morrison, et al.21 in a randomized sure to minimize re-bleeding. Despite the controversy of
clinical trial involving 90 patients found that patients re- type of fluid to be used, permissive hypotension aims to
suscitated to 55 millimeter mercury received significant- achieved mean arterial pressure of up to 60 millimeter
ly less blood products and total intra venous fluid during mercury.16 Mean artery pressure of 60 millimeter mer-
intraoperative resuscitation than those resuscitated to 65 cury is sufficient to preserve organ perfusion while avoid
millimeter mercury. Patients resuscitated to 55 millime- re-bleeding.16
ter mercury also had significantly lower mortality in the
Conclusions
early postoperative period and a nonsignificant trend for
Recent evidences support the application of small vol-
lower mortality at 30 days.
ume fluid resuscitation. The benefits of small volume flu-
Based on those studies, permissive hypotension con-
id resuscitation is emphasized especially in cases where
cept as introduced by Canon has now regained its pop-
control of bleeding could not be achieved.
ularity. This concept utilizes small volume of fluid to

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