SHOCK TREATMENT CHOICES 2

Hypertonic Saline


The logic behind the use of hyperosmotic soultions in patients with hypovolemic shock is
-The hypertonic component of these solutions draws water out of the intracellular space and expands the volume of the extracellular space.
-To increase the intravascular osmotic pressure 6% dextran has been added to the hypertonic saline solution.
-The colloid component holds the newly arrived readmitted fluid in the intravascular space and thus, should prolong the beneficial effects of the hypertonic solutions. Based on published data, hypertonic saline with or without dextran offers a little benefit than standard resuscitation regimes.
• In-patients with shock and traumatic brain injury the brain edema hypertonic saline may offer some benefit in the form reducing edema.
• Hypertonic saline as method of small volume resuscitation may also offer some advantages in prolonged transport or longer evacuation periods times require of resuscitation with limited supplies.
• Additionally, the small weights and volumes of hypertonic saline required for resuscitation may prove of advantage in stored supplies for the war and disasters.
Use of Colloids


It is uncertain whether the use of colloid solutions has any benefit over the use of crystalloid solutions.
Analysis of randomized, controlled trials, comparing albulmin to crystalloid, have suggested that use of colloid solutions, in resuscitation may in fact increase mortality.
It is thought that albumin, for instance may increase edema , impair sodium and water exeretion, and worsen renal failure.
There are two forms of synthetic colloid in use.
-Hetastarch, a 6% hydroxyethyul starch solution, has a significant volume expanding effect that lasts as long as 24 hours.
-Potential disadvantages with the use of hetastarch, include rare anaphylaetic reactions, and the development of a coagulopathy, when given in excess of 100ml/day.
Clinical trials, with this agent have shown improvements in tissue perfusion, without any difference, in clinical outcomes.
-Pentastarch is a synthetic colloid, with several advantages over hetastarch.
Its structure allows for a more concentrated solution, and therefore higher osmotic pressures, for plasma expansion, and faster plasma clearance, and renal excretion
This new solution, has been proved to cause less allergy, and is associated with fewer renal, or anaphylactic complications.
Pentastarch has a volume expanding effect that lasts approximately 12 hours in comparison to herastarch (24 hours). Approximately 90% of the pentastarch given is eliminated form the intravascular space within 24 hours.
Pentastarch induces plasma volume expansion of about 1.5 times the volume introduced, whereas hetastarch produces expansion approximately equal to the volume administered.
Thus pentastarch may be a more potent volume expander with a shorter duration of action than either hetastarch or albumin
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