高渗盐水在颅脑外伤合并失血性休克中的应用

高渗盐水在治疗失血性休克尤其是合并颅脑外伤中应用越来越广泛。国内外研究均提示其在颅脑外伤治疗中有积极作用：能避免大脑血流因灌注减少引起的缺血、缺氧。减轻大脑的二次损伤。然而国外的学者通过研究发现高渗盐水在提高患者的远期预后方面仍存在着很大的争议,因此对于其能否在临床上推广．仍需更多的大样本实验来证实。     

高渗复合液治疗失血性休克的机制研究

目的　研究高渗复合液的脱水作用治疗失血性休克的机制。方法　利用大鼠Wigger′s失血性休克模型 ,通过对比不同复苏液对大鼠下肢腓肠肌水含量的影响来评价高渗复合液的作用效果。结果　在出血性休克并复苏后 ,高渗复合液组的组织水含量 (73 0 %± 1 5 % )较平衡液组(74 8%± 2 0 % )及对照组 (75 4 %± 1 6 % )少 ,差异有显著意义 (P <0 0 5 )。结论　高渗复合液无论在休克状态与水肿状态均可以将细胞和间隙内的水分抽取至血管内 ,从而扩大血容量。     

高渗盐溶液治疗失血性休克

目的探讨应用高渗盐溶液救治失血性休克的优越性。方法在本科近期收治的20例失血性休克患者的抢救过程中,将10%的氯化钠配成7.5%的高渗氯化钠溶液300ml,早期一次性静脉输注,随后用等渗盐水或低分子右旋糖酐维持,疗效满意,且无副反应发生。结果20例失血性休克患者中,除2例多发伤患者应用高渗盐溶液后无效死亡外,其余均抢救成功。结论对失血性休克的救治,高渗盐溶液是一种安全有效的方法,它可以快速恢复血压,改善微循环系统,显著减少液体用量,且未出现并发症。     

高渗盐水右旋糖酐液抗失血性休克机理的研究进展

近年来的实验表明，高渗盐水右旋糖杆－７０（ＨＳＤ）抗失性休克效果明显优于单纯高渗盐水（ＨＳ）。ＨＳＤ的抗失血性休克机理与其能迅速扩充血浆容量、增加心肌收缩力、扩张毛细血管、降低外周血管阻力及通过右旋糖杆－７０较长时间地维持高渗盐的作用有关。     

高渗盐液在伴有失血性休克颅脑创伤中的应用

颅脑创伤后发生的脑缺氧造成继发性脑损伤,低血压是其中的一个重要因素。高渗盐液(HS)复苏Q0快速纠正颅脑损伤者的低血压状态,同时能降低颅内压(ICP),改善脑血流状况,从而减少复苏所需的液体量和减轻继发脑损害的程度,提高此类病人的存活率。     

早期限制性液体复苏在重型颅脑损伤合并创伤性失血性休克救治中的应用

目的总结重型颅脑损伤合并刨伤性失血性休克患者早期采用限制性液体复苏的救治经验。方法对2003年1月至2009年12月间收治的91例重型颅脑损伤合并休克患者的临床资料进行回顾性分析,比较常规大量液体复苏和限制性液体复苏的治疗效果。结果重型颅脑损伤合并休克的患者,早期采用限制性液体复苏是合理有效的措施,限制性液体复苏组和常规液体复苏组在入院24小时及1周内的死亡率虽都无显著差异,但限制性液体复苏组1周时的死亡率要更低,出院时限制性液体复苏组预后良好（GOS分级Ⅳ～Ⅴ）的比率则更是显著高于常规液体复苏组。结论早期采用限制性液体复苏可以提高重型颅脑损伤合并创伤性失血性休克患者的救治成功率和远期预后。     

高渗盐溶液复苏的研究进展

创伤失血性动作用小溶量高渗盐溶液治疗,有利于防止继发性细菌感染,高渗盐溶液中减轻颅脑损伤后继发性脑水肿,颅内高压,高渗醋钠及其复方溶液在改善酸碱平衡及外周期环方面有其独到之处。     

Hypertonic saline solution resuscitation in hemorrhagic shock dogs

Objective: To find out the optimal concentration,infusion rate and dosage of saline for resuscitation. Methods: Forty-five dogs were used to establish hypovolemic shock models. The dogs were resuscitated with saline of different concentrations and different dosages under different infusion rates, and the resuscitation results were compared. Results: The best concentration was 7.5%, the best rate of infusion 20 ml/min ( a volume equivalent to 15 % of the shed blood ) and the best dosage 5.71 ml/kg. The method was effective for resuscitation, the mean arterial pressure (MAP) could be elevated to 89 % of the baseline,and this MAP could be kept for more than one hour. Conclusions： Using 7.5% sodium chloride solution equivalent to 15% of the shed blood at an infusion rate of 20 ml/min can achieve a best resuscitation result.     

高渗氯化钠羟乙基淀粉复合液对失血性休克肺的保护作用

目的观察用高渗氯化钠羟乙基淀粉复合液(7.5%氯化钠 6%羟乙基淀粉200/0.5,HHS)小容量复苏对失血性休克后肺损伤的影响。方法雄性SD大鼠随机分为五组:正常对照组(CON组,n=6):不放血不补液;其他大鼠通过放血使MAP降至45mmHg并维持120min,然后分为:休克组(SH组,n=6),不补液复苏;HHS组(n=8),用HHS5ml/kg静脉滴注;7.5%氯化钠高渗溶液组(HTS组,n=6),用7.5%NaCl5ml/kg静脉滴注;复方乳酸钠组(LR组,n=7),用3倍失血量的复方乳酸钠静脉滴注。观察休克2h末、补液结束即刻、15、30、60、120、180min时MAP、CVP的变化,测定补液结束2、24h存活动物的氧合指数和肺水含量、肺髓过氧化物酶(MPO)水平、肺损伤评分。结果在补液结束120、180min,HTS组MAP、CVP低于HHS和LR组(P<0.05);在补液结束24h,HHS组氧合指数、肺水含量、肺MPO水平、肺损伤评分优于HTS和LR组(P<0.05)。结论用HHS小容量复苏失血性休克,维持血流动力学稳定时间更长;对肺组织的保护作用优于7.5%氯化钠高渗溶液或复方乳酸钠。     

6%羟乙基淀粉130/0.4液体复苏对创伤性脑损伤合并失血性休克大鼠的脑保护作用

目的 探讨6%羟乙基淀粉130/0.4(6%HES 130/0.4)液体复苏对创伤性脑损伤合并失血性休克大鼠的脑保护作用.方法 健康成年雄性SD大鼠60只,体重300～350 g,随机分为5组(n=12):假手术组(S组)、模型组(M组)、生理盐水组(NS组)、6%.HES 130/0.4组(HES组)和晶体.胶体高渗透压混合液组(HHS组).分别参照Feeney改良法和Wiggers改良法制备大鼠创伤性脑损伤模型和失血性休克模型.S组仅切开头皮,钻开骨窗,不制备创伤性脑损伤和失血性休克模型;M组制备创伤性脑损伤和失血性休克模型;其余3组均制备创伤性脑损伤和失血性休克模型,并于休克60 min时开始复苏.NS组经股静脉输注3倍于放血量的生理盐水;HES组经股静脉输注等于放血量的6%HES 130/0.4;HHS组经股静脉输注等于放血量的HHS(10%HES 130/0.4与7.5%NaCl按1:1混合),各复苏组均在30 min内将液体输注完毕.实验期间记录平均动脉压(MAP),采用ELISA法测定血清S-100β蛋白浓度;于复苏180 min时取脑组织,计算脑组织含水量,采用EUSA法测定脑组织TNF-α和IL-6的含量.结果 与M组比较,NS组、HES组和HHS组复苏后MAP和脑组织含水量升高,HES组脑组织TNF-α和IL-6的含量降低,HES组和HHS组复苏后血清S-100蛋白浓度降低(P<0.05),NS组血清S-100β蛋白浓度差异无统计学意义(P>0.05);与NS组比较,HES组和HHS组复苏后MAP升高,脑组织含水量和血清S-100β蛋白浓度均降低,HES组脑组织TNF-α和IL-6的含量降低(P<0.05);与HES组比较,HHS组脑组织TNF-α和IL-6的含量升高,血清S-100β蛋白浓度升高(P<0.05),MAP差异无统计学意义(P>0.05).结论 6%HES 130/0.4液体复苏可对创伤性脑损伤合并失血性休克大鼠产生脑保护作用,且该作用强于HHS,其脑保护作用的机制可能与降低脑组织炎性反应有关.     

Hypertonic saline prevents early bacterial translocation in hemorrhagic shock

The most appropriate solution for volume replacement in hemorrhagic shock is controversial; however, hypertonic saline (HTS) solutions have recently gained widespread acceptance. In this study, various solutions were used to resuscitate rats in hemorrhagic shock, and their impact on the extent of bacterial translocation was investigated. Rats were bled to a mean arterial blood pressure of about 35 mmHg which was maintained for 30 min. They were then randomized into six groups. Blood pressure was found to be regulated by blood + lactated Ringer's solution (LR) and HTS+LR, but no significant improvement was observed in the control and LR groups. Groups II (7.5% HTS+60 ml/kg LR) and IV (60 ml/kg LR + autologous blood) had a significantly better result than groups I (7.5% HTS), III (60 ml/kg LR), and IV (P<0.05), among which no statistically different results were seen (P>0.05). While no organisms were isolated from the mesenteric lymph nodes in the sham group, the rates of positive culture were 12.5%, 12.5%, 50%, 62.5%, and 62.5% in groups I, II, III, and the control group, respectively.Escherichia coli was the most commonly isolated organism. HTS+LR was demonstrated to be effective for decreasing the rate of early bacterial translocation to mesenteric lymph nodes and also for restoring the mean arterial pressure.     

Hypertonic saline in the traumatic hypovolemic shock: meta-analysis

Background

A wealth of evidence from animal experiments has indicated that hypertonic saline (HS) maybe a better choice for fluid resuscitation in traumatic hypovolemic shock in comparison with conventional isotonic saline. However, the results of several clinical trials raised controversies on the superiority of fluid resuscitation with HS. This meta-analysis was performed to better understand the efficacy of HS in patients with traumatic hypovolemic shock comparing with isotonic saline.

Materials and methods

According to the search strategy, we searched the PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, which was completed on October 2013. After literature searching, two investigators independently performed the literature screening, assessment of quality of the included trials, and data extraction. Disagreements were resolved by consensus or by a third investigator if needed. The outcomes included mortality, blood pressure, fluid requirement, and serum sodium.

Results

Six randomized controlled trials were included in the meta-analysis. The pooled risk ratio for mortality at discharge was 0.96 (95% confidence interval [CI], 0.82–1.14), whereas the pooled mean difference for the change in systolic blood pressure from baseline and the level of serum sodium after infusion was 6.47 (95% CI, 1.31–11.63) and 7.94 (95% CI, 7.38–8.51), respectively. Current data were insufficient to evaluate the effect of HS on the fluid requirement for the resuscitation.

Conclusions

The present meta-analysis was unable to demonstrate a clinically important improvement in mortality after the HS administration. Moreover, we observed HS administration maybe accompanied with significant increase in blood pressure and serum sodium.     

Hypertonic saline: a clinical review

Literature suggest that hypertonic saline (HTS) solution with sodium chloride concentration greater than the physiologic 0.9% can be useful in controlling elevated intracranial pressure (ICP) and as a resuscitative agent in multiple settings including traumatic brain injury (TBI). In this review, we discuss HTS mechanisms of action, adverse effects, and current clinical studies. Studies show that HTS administered during the resuscitation of patients with a TBI improves neurological outcome. HTS also has positive effects on elevated ICP from multiple etiologies, and for shock resuscitation. However, a prospective randomized Australian study using an aggressive resuscitation protocol in trauma patients showed no difference in amount of fluids administered during prehospital resuscitation, and no differences in ICP control or neurological outcome. The role of HTS in prehospital resuscitation is yet to be determined. The most important factor in improving outcomes may be prevention of hypotension and preservation of cerebral blood flow. In regards to control of elevated ICP during the inpatient course, HTS appears safe and effective. Although clinicians currently use HTS with some success, significant questions remain as to the dose and manner of HTS infusion. Direct protocol comparisons should be performed to improve and standardize patient care.     

Relationship between trauma-induced coagulopathy and progressive hemorrhagic injury in patients with traumatic brain injury

Progressive hemorrhagic injury (PHI) can be divided into coagulopathy-related PHI and normal coagulation PHI. Coagulation disorders after traumatic brain injuries can be included in trauma-induced coagulopathy (TIC). Some studies showed that TIC is associated with PHI and increases the rates of disability and mortality. In this review, we discussed some mechanisms in TIC, which is of great importance in the development of PHI, including tissue factor (TF) hypothesis, protein C pathway and thrombocytopenia. The main mechanism in the relation of TIC to PHI is hypocoagulability. We also reviewed some coagulopathy parameters and proposed some possible risk factors, predictors andtherapies.     

Volume replacement with lactated Ringer's or 3% hypertonic saline solution during combined experimental hemorrhagic shock and traumatic brain injury

BACKGROUND: The devastating effects of hypotension on head-trauma-related mortality are well known. This study evaluates the systemic and cerebral hemodynamic responses to volume replacement with 3% hypertonic saline (HSS) or lactated Ringer's solution (LR), during the acute phase of hemorrhagic shock (HS) associated with traumatic brain injury (TBI). METHODS: Fifteen dogs were assigned to one of three groups (n = 5, each) according to the volume replacement protocol, infused after TBI (brain fluid percussion, 4 atm) and epidural balloon to an intracranial pressure (ICP) higher than 20 mm Hg and HS, induced by blood removal to a mean arterial pressure (MAP) of 40 mm Hg in 5 minutes: Group HS+TBI+HSS (8 mL/kg of 3% HSS), HS+TBI+LR (16 mL/kg LR), and Group HS+TBI (controls, no fluids). We simulated treatment during prehospital and early hospital admission. Groups HS+ TBI and HS+TBI+LR received shed blood infusion to a target hematocrit of 30%. Measurements included shed blood volume, fluid volume infused to restore MAP, MAP, cardiac output, cerebral perfusion pressure, cerebral and systemic lactate, and oxygen extraction ratios. RESULTS: Fluid replacement with HSS 3% or LR promoted major hemodynamic benefits over control animals without luids. Cerebral perfusion pressure was higher than controls and similar between treated groups; however, HSS 3% infusion was associated with lower ICP during the "early hospital phase" and a higher serum sodium and osmolarity. CONCLUSION: In the event of severe head trauma and hemorrhagic shock, the use of HSS 3% and larger volumes of LR promote similar systemic and cerebral hemodynamic benefits. However, a lower ICP was observed after HSS 3% than after LR.     

23.4%高渗盐水治疗重型颅脑损伤并颅内高压效果分析

目的探讨23.4%高渗盐水治疗重型颅脑损伤并颅高压的效果。方法随机将100例重型颅脑损伤并颅高压患者分为2组,各50例。观察组输注23.4%高渗盐水,对照组给予20%甘露醇。比较2组颅内压监测时间、ICU住院时间,2周病死率,颅内压高负荷的累积率及每日颅内压高负荷时间的差异。结果观察组的ICU住院时间少于对照组,颅内压高负荷的累积率及每日颅内压高负荷的时间低于对照组,差异有统计学意义(P0.05);2组ICP监测时间与2周病死率差异无统计学意义(P0.05)。结论对重型颅脑损伤患者快速注射高渗盐水在降低颅内压高负荷的累积率及颅内压高负荷时间比甘露醇效果更好,可缩短重型颅脑损伤患者的ICU住院时间。     

高渗氯化钠羟乙基淀粉溶液对失血性休克兔应激反应的影响

目的国观察高渗氯化钠羟乙基淀粉溶液(HHS)对失血性休克兔应激反应的影响。方法 14只兔随机分为HHS组和乳酸盐林格液组(LBS组),每组7只。采用Wiggers改良法制作失血性休克模型,休克后45 min后分别用6 ml／kg的HHS和LRS复苏。在休克前、复苏前、复苏后30、60和120min时取血标本,测定血浆肾上腺素、胰高血糖素、胰岛素及血糖的浓度,计算胰岛素敏感指数(ISI)。结果 与休克前比较,复苏前两组动物血浆肾上腺素、胰高血糖素和血糖浓度均升高,胰岛素浓度均降低(P<0.01);复苏后,HHS组动物血浆肾上腺素、胰高血糖素水平回落,胰岛素浓度升高(P<0.05或0.01),LRS组动物血浆肾上腺素、胰岛素和血糖浓度均升高(P<0.01);HHS组复苏后各时点血浆肾上腺素、复苏后120 min时胰高血糖素、复苏后60 min时胰岛素浓度、复苏后60及120 min时血糖浓度均较低于LRS组(P<0.05或0.01)。复苏期间,两组动物胰岛素敏感指数均较休克前降低(P<0.05或0.01),但HHS组在复苏120 min时恢复至休克前水平(P>0.05)。HHS组于复苏后60、120 min ISI均高于LRS组(P<0.05或0.01)。结论 HHS复苏能够降低失血性休克应激激素水平,阻止胰岛素敏感性下降。