Abbreviated laparotomy

The decision to perform damage control laparotomy in a critically injured patients depends on the risk of life-threatening coagulopathy. The main decision criteria are: presence of concomitant injuries, patient history, shock, transfusion volume, hypothermia and acidosis. The aim of surgery is to achieve satisfactory hemostasis, limit peritoneal thermal loss, and perform physiological restoration as rapidly as possible in the intensive care unit. This includes gauze packing of major liver or retroperitoneal injuries and ligation of injured blood vessels. Injuries to the intestine and the urinary tract are sutures, stapled or drained. If the skin borders cannot be reapproximated because of excessive abdominal tension, a wall prosthesis should be used to avoid abdominal compartment syndrome. Reoperation is a dangerous procedure in the immediate postoperative period but must be proposed later for reexploration or damage repair.     

Abbreviated laparotomy in severe abdominal trauma

On critically injured patient the decision to perform a damage control laparotomy is based on the volume of transfusion and shock. The aim of the surgery which is to obtain as fast as possible the best hemostasis to limit the peritoneal thermal loss and to perform as soon as possible physiologic restoration in the Intensive Care Unit.     

Abbreviated laparotomy and planned reoperation for critically injured patients.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.     

Abbreviated emergency laparotomy in the non-trauma setting

Background  

Although the application of damage control surgery for trauma has been widely reported and defined, similar approach in non-trauma patients has not been well detailed.     

Vascular tone in patients with hemorrhagic shock.

BACKGROUND: In hemorrhagic shock, the alterations in arterial vascular tone, which are primarily regulated by adrenosympathetic influences are compensatory responses to bleeding. OBJECTIVE: The aim of this study was to evaluate vascular tone expressed by the volume elastic modulus (Ev) as a clinical monitor to detect the hypovolemic state. METHODS: Thirteen patients with hemorrhagic shock were studied. The initial Ev measurement was performed at arrival, and subsequent measurements were obtained 4 and 12 hours after arrival. Patients were divided into two groups by cluster analysis by using the Ev values at arrival and 4 hours after arrival. Circulatory parameters, the clinical course, and fluid were compared. RESULTS: The Ev values were identical at admission (cluster I vs. II: 456.4+/-197.1 vs 566.1+/-234.1 mm Hg, mean +/- SD). After 4 hours of fluid resuscitation, all patients were recovered from shock. In cluster I, the Ev remained high at 4 hours (523.4+/-75.1 mm Hg) and invasive treatments for hemostasis were required. In cluster II, the Ev significantly decreased at 4 hours (182.8+/-70.7 mm Hg, p < 0.01) and clinical courses were eventless thereafter. During 4 to 12 hours, more fluid was given in cluster I (p < 0.05). At 12 hours after arrival, the Ev values were identical in both clusters. CONCLUSION: These data demonstrate that the Ev increases in hemorrhagic shock. Furthermore, normotensive hypovolemic conditions generated by persistent bleeding can be detected by measuring the Ev.     

高氧液在抢救重度失血性休克中的临床应用

目的　观察高氧液对重度失血性休克患者血压和微循环的影响。方法　选择重度失血性休克患者 6 0例 ,随机分为治疗组和对照组 ,每组 30例。每组在抢救中除采用止血、输血、输液等相同措施外 ,对照组输入复方乳酸钠 10～ 2 0ml/kg ;治疗组输入等量的高氧液。两组同步观测血压、尿量、血气恢复正常及末梢循环改善所需要的时间。结果　治疗组血压、尿量、血气恢复正常及末梢循环改善所需要的时间均较对照组少 (P <0 0 1)。结论　高氧液对重度失血性休克有稳定血压和改善微循环的作用。     

右美托咪定对失血性休克患者肾功能的影响

目的探讨术中使用右美托咪定对失血性休克患者肾功能的影响。方法选择本院拟行急诊全麻下手术治疗的失血性休克患者60例,男27例,女33例,年龄18~69岁,ASAⅢ或Ⅳ级。将患者随机分为两组:右美托咪定组(D组)和对照组(C组),每组30例。两组患者均在手术止血的同时积极进行容量复苏治疗,D组在麻醉诱导后切皮前给予右美托咪定0.5μg/kg,给药时间10min,随后以0.4μg·kg~(-1)·h~(-1)的速率静脉输注至术毕前30min,C组给予等容量的生理盐水。分别于切皮前即刻(T_1)、术毕即刻(T_2)、术毕24h(T_3)、术毕72h(T_4)时采集静脉血样,检测血清肌酐(Scr)和尿素氮(BUN)浓度、中性粒细胞明胶酶相关脂质运载蛋白(NGAL)和高迁移率族蛋白1(HMGB1)含量,计算并比较T_4时血清Scr浓度和T_3时HMGB1含量较T_1时的变化幅度(ΔScr和ΔHMGB1),并记录患者T_1、T_2时MAP、HR等血流动力学指标和剩余碱(BE)、乳酸(Lac)等动脉血气结果。结果与T_1时比较,T_2时两组MAP、CVP和BE明显升高,HR和Lac明显降低(P0.05),组间比较无统计学差异。与T_1时比较,T_3、T_4时D组血清Scr浓度明显降低(P0.05);D组ΔScr明显小于C组(P0.05)。两组患者各时点血清BUN浓度差异无统计学意义。与T_1时比较,T_4时D组血清NGAL含量明显减少(P0.01);T_4时D组血清NGAL含量明显少于C组(P0.05)。与T_1时比较,T_2时两组患者血清HMGB1含量明显减少(P0.05);T_3时C组血清HMGB1含量明显增加(P0.01);T_3时C组血清HMGB1含量明显多于D组(P0.05);C组ΔHMGB1明显大于D组(P0.05)。结论右美托咪定可抑制缺血-再灌注后血清促炎因子HMGB1含量的增加,有利于失血性休克患者肾功能的恢复。     

Hypertonic resuscitation modulates the inflammatory response in patients with traumatic hemorrhagic shock

OBJECTIVE: To determine the effect of resuscitation with hypertonic saline/dextran (HSD) on the innate immune response after injury. SUMMARY OF BACKGROUND DATA: Hypovolemic shock causes a whole body ischemia/reperfusion injury, leading to dysregulation of the inflammatory response and multiple organ dysfunction syndrome. Hypertonicity has been shown to modulate the innate immune response in vitro and in animal models of hemorrhagic shock, but the effect on the inflammatory response in humans is largely unknown. METHODS: Serial blood samples were drawn (12, 24, 72 hours and 7 days after injury) from patients enrolled in a prospective, randomized, double-blind trial of traumatic hypovolemic shock, HSD (250 mL) versus lactated Ringer's solution (LR) as the initial resuscitation fluid. Neutrophil (PMN) CD11b/CD18 expression was assessed via whole blood FACS analysis with and without stimulation (fMLP 5 micromol/L or PMA 5 micromol/L). PMN respiratory burst was assessed using the nitro-blue tetrazolium assay. Monocytes stimulated with 100 ng LPS for 18 hours were assessed for cytokine production (TNF-alpha, IL-1Beta, IL-6, IL-10, IL-12). RESULTS: Sixty-two patients (36 HSD, 26 LR) and 20 healthy volunteers were enrolled. CD11b expression, 12 hours after injury, was increased 1.5-fold in patients resuscitated with LR compared with controls. Those resuscitated with HSD had a significant reduction in CD11b expression 12 hours after injury, compared with LR. There was no difference in respiratory burst early after injury. Monocytes from injured patients expressed lower levels of all cytokines in comparison to normal controls. Patients give HSD showed a trend toward higher levels of IL-1beta and IL10 production in response to LPS, 12 hours after injury. CONCLUSION: HSD resuscitation results in transient inhibition of PMN CD11b expression and partial restoration of the normal monocyte phenotype early after injury.     

Vasopressin in hemorrhagic shock

We describe the treatment of two patients with hemorrhagic shock unresponsive to volume replacement and catecholamines. Both patients responded to a small-dose infusion of vasopressin, which allowed tapering off of the catecholamines. The possible role of small-dose infusions of vasopressin in fluid- and catecholamine-resistant hemorrhagic shock is discussed.     

消化道大出血并发休克的液体疗法

消化道大出血并发休克是普外科医生常见的紧急情况。出血性休克的治疗包括维持血压和组织灌注、直到出血被控制。具体治疗方法是止血、输血和输液。对休克的输液治疗又被称为输液复苏或液体复苏。然而 ,临床医师常遇到的情况是 :在病人出血被控制之前 ,输液复苏治疗虽能维持血压 ,防止休克 ,但由于应用不同的输液 ,也可加重出血或诱发心衰。因此 ,本文结合近年来的研究结果 ,对出血并发休克的病人如何进行有效合理的输液复苏进行探讨。一、动物实验研究尽管近来的研究对早期输液复苏的益处有所置疑 ,但有关早期输液复苏的动物实验研究证明 ,…     

减阻剂用于出血性休克复苏的实验研究

Drag reducing polymers （DRPs） provide large drag reductions iu turbulent flow at nanomolar concentrations of linear macropolymers,as polyethylene glycol, aloe vera polymer. DRPs have been shown to significantly enhance hemodynamics and improve microcirculation, make the red blood cells work harder and increase blood pressure , improve survival in hemorrhagie shock.     

Current concepts in hemorrhagic shock

Treatment of hemorrhagic shock continues to evolve. Surgically, the concept of "damage control" has become the standard, with shorter operations focused on the control of life-threatening injuries. For the anesthesiologist, practice has changed, with a better understanding of the pathophysiology of shock, new techniques such as deliberate hypotension and perfusion-focused therapy, improved management of transfusion, and the advent of systemic hemostatic drug therapy. In this article, the author reviews each of these topics, and presents an integrated recommendation for early and late management of the patient in hemorrhagic shock.     

Adrenal insufficiency in hemorrhagic shock

Adrenal insufficiency during sepsis is well documented. The association between hemorrhagic shock and adrenal insufficiency is unclear and may be related to ischemia, necrosis, or resuscitation. This study was designed to determine the incidence of relative adrenal insufficiency in hemorrhagic shock. A retrospective review of a prospectively gathered database for patients admitted to the trauma intensive care unit with hemorrhagic shock was undertaken. A random serum cortisol of <25 mcg/dL defined relative adrenal insufficiency. All of the cortisol levels were drawn within the first 24 hours of admission. Data analyzed included demographics, length of stay, injury mechanism, infections, and mortality. Fifteen patients presented with hemorrhagic shock, with 14 of 15 meeting the criteria for relative adrenal insufficiency. The average serum cortisol level was 15.8 (9-26.8). The average APACHE II score was 18.3 (4-33), and the average Injury Severity Score was 22.5 (8-41). The mechanism was blunt trauma in 10 patients and penetrating trauma in 5. The average intensive care unit and hospital length of stay were 13.2 and 27.4 days, respectively. There were five urinary tract infections, four blood stream infections, and two wound infections. Two of the 15 patients died. Relative adrenal insufficiency appears to be common in hemorrhagic shock. Future research is warranted to elucidate the pathophysiology, as well as to prospectively determine which patients may benefit from steroid replacement.     

高渗盐水和山莨菪碱治疗失血性休克34例临床观察

失血性休克是临床常见的危急重病,迅速有效地恢复和维持血容量是失血性休克急救复苏的关键措施之一.而预防术后多器官功能障碍综合征(MODS)的出现,也是提高抢救成功率的重要原因之一.……