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Hypertonic saline dextran/starch

atacc.doc at virgin.net atacc.doc at virgin.net
Fri Apr 28 11:47:02 BST 2006

Dear List members,
In our pre-hospital and resuscitation work when we do feel that a fluid bolus is required (eg lost radial pulse), we regulalry use hypertonics (with dextran or starch) and have done so for >5years.
I am unaware of any definitive trial to show isignificantly improved outcome, although many have 'strongly suggested' an improvement, especially in TBI+shock (summarised in the original Wade Meta-analysis and several more recent literature reviews eg J trauma - 2003, NICE, UK Consensus Guidelines, 2002 etc)
The definitive trial is certainly not likely to be produced, at least in our part of the world, as proving that 50-250ml HSD given pre-hospital will alter the mortality of a trauma patient who is about to enter a poorly controlled trauma 'machine' involving paramedics, A&E, theatre, ICU etc etc and all the inevitable interventions, is impossible for us and most others! Good luck to anyone who tries!
So there is no solid EB, but where is it for the current SOC????
Hypertonics used in small volumes and applying permissive hypotension principles can rapidly restore an 'adequate' BP whilst avoiding many of the issues of cyclic-hyperesuscitation.
They effectively and rapidly restrore blood pressure and their safety in resuscitation has been repeatedly demonstrated over the last 20 years (Mauritz, Wasser, Dubick, Wade etc).
They reliably and reproducibly reduce intracranial pressure, without rebound.
Most importantly for us, they have distinct practical advantages in terms of fluids volumes carried, speed of administration and response (especially as they can even be delivered through a small bore cannulae when cannulation is difficult). They are safe and 'may' improve outcome, especially if in a shocked TBI.
Bottom line, they are not that cheap at present, but costs will fall. You need to decide if the real practical benefits and the potential advantages of these products for your patients justifies the cost. 
We administer fluids only to the most seriously shocked casualties, so our costs have been minimised but given the choice of a Level-1 infusor or a 250ml bag of HSS/HSD in major haemorrhage, then I would take the hypertonic which will rapidly create a window of opportunity to get to the OR.
Mark Forrest
ATACC Medical Director,UK

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