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Cardiovascular Effect of 7.5% Sodium Chloride Dextran Infusion After

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Cardiovascular Effect of 7.5% Sodium Chloride Dextran Infusion After ORIGINAL ARTICLE Cardiovascular Effect of 7.5% Sodium Chloride–Dextran Infusion After Thermal Injury Joseph T. Murphy, MD; Jureta W. Horton, PhD; Gary F. Purdue, MD; John L. Hunt, MD Hypothesis: Clinical study can help determine the safety RL alone (mean ± SEM, 0.45 ± 0.32 vs 1.35 ± 0.35 µg/L and cardiovascular and systemic effects of an early infu- at 8 hours, 0.88 ± 0.55 vs 2.21 ± 0.35 µg/L at 12 hours). sion of 7.5% sodium chloride in 6% dextran-70 (hyper- While cardiac output increased proportionately be- tonic saline–dextran-70 [HSD]) given as an adjuvant to tween 4 and 24 hours in both groups (from 5.79 ± 0.8 to a standard resuscitation with lactated Ringer (RL) solu- 9.45 ± 1.1 L/min [mean ± SEM] for HSD vs from 5.4 ± 0.4 tion following severe thermal injury. to 9.46 ± 1.22 L/min for RL), filling pressure (central ve- nous pressure and pulmonary capillary wedge pressure) Design: Prospective clinical study. remained low for 12 hours after HSD infusion (P = .048). Total fluid requirements at 8 hours (2.76 ± 0.7 mL/kg per Setting: Intensive care unit of tertiary referral burn care each 1% TBSA burned [mean ± SEM] for HSD vs center. 2.67 ± 0.24 mL/kg per each 1% TBSA burned for RL) and 24 hours (6.11 ± 4.4 vs 6.76 ± 0.75 mL/kg per each 1% TBSA Patients: Eighteen patients with thermal injury over burned) were similar. Blood pressure remained un- more than 35% of the total body surface area (TBSA) changed, and serum sodium levels did not exceed 150 ± 2 (range, 36%-71%) were studied. mmol/L (mean ± SD) in either group. Interventions: Eight patients (mean ± SEM, 48.2% ± 2% Conclusions: The absence of deleterious hemody- TBSA) received a 4-mL/kg HSD infusion approximately namic or metabolic side effects following HSD infu- 3.5 hours (range, 1.5-5.0 hours) after thermal injury in sion in patients with major thermal injury confirms addition to routine RL resuscitation. Ten patients the safety of this resuscitation strategy. Postburn car- (46.0% ± 6% TBSA) received RL resuscitation alone. diac dysfunction was demonstrated in all burn patients through the use of cardiospecific serum markers and Main Outcome Measures: Pulmonary artery cath- pulmonary artery catheter monitoring. Early adminis- eters were employed to monitor cardiac function, while tration of HSD after a severe thermal injury may hemodynamic, metabolic, and biochemical measure- reduce burn-related cardiac dysfunction, but it had no ments were taken for 24 hours. effect on the volume of resuscitation or serum bio- chemistry values. Results: Serum troponin I levels, while detectable in all patients, were significantly lower after HSD compared with Arch Surg. 1999;134:1091-1097 ARGE-VOLUME infusion of a Recent studies have described the use balanced sodium solution of hypertonic solutions for primary resus- has been a mainstay in the citation and as adjuvant fluid therapy for resuscitation of the se- patients subject to a variety of traumatic in- verely injured patient for de- sults.3-9 The studies examining the effi- Lcades. Of special concern to physicians in- cacy of hyperosmolar solutions in restor- volved with resuscitation of the thermally ing intravascular volume after thermal injured are the consequences of adminis- injury or hypovolemic shock frequently tering the enormous fluid volume re- showed promising results under very quired for maintenance of mean arterial strictly controlled clinical conditions. De- blood pressure and urine output. This con- spite these findings, the hemodynamic and From the Division of Burns, Trauma, and Critical Care, cern stems from the recognition that mor- cardiovascular effects of a hypertonic sa- Department of Surgery, bidity associated with volume overload line–dextran (HSD) bolus in the resusci- University of Texas may be quite severe, particularly pulmo- tation of large thermal injury remained un- Southwestern Medical Center, nary and cardiac decompensation related clear. Animal studies from our laboratory Dallas. to edema.1,2 and others have shown that a small bolus ARCH SURG/ VOL 134, OCT 1999 WWW.ARCHSURG.COM 1091 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Patient Demographic and Injury Characteristics* PATIENTS AND METHODS HSD+RL RL Alone (n=8) (n = 10) This prospective clinical study was conducted at a Age, y 32 ± 2 35 ± 4 tertiary burn referral center in patients with thermal Sex, M/F 5/3 7/3 injury involving at least 35% TBSA. Inclusion crite- Weight, kg 76 ± 5 79 ± 2 ria included age between 18 and 66 years, thermal TBSA, % 48 ± 2 46 ± 6 injury greater than or equal to 35% TBSA, and hos- Full-thickness TBSA, % 11 ± 8 13 ± 5 pital admission within 6 hours of thermal injury. Pa- tients were excluded from consideration for a his- *HSD indicates hypertonic saline–dextran-70; RL, Ringer lactate; and tory of renal disease, bleeding disorder, multisystem TBSA, total body surface area. Values are mean ± SEM unless otherwise trauma, inhalation injury, and pregnancy. Patient par- indicated. ticipation was in accordance with informed consent guidelines and restrictions approved by the Institu- tional Review Board of the University of Texas South- solutions have long been known to have positive inotro- western Medical Center at Dallas. pic effects and may enhance myocardial contractility Eighteen patients were enrolled in this study. through the stimulation of sodium-calcium exchange at Prior to initial assessment, all patients received stan- the myocyte membrane.14 Other mechanisms may in- dard-volume resuscitation of RL solution as dic- volve autonomic nervous system stimulation or enhance- tated by the Parkland guidelines (4 mL/kg per 1% ment of pulmonary-cardiac reflexes.15 TBSA burned, with half the total given over the ini- We had previously examined the hemodynamic tial 8 hours). All patients underwent intubation, and effects of delayed hypertonic saline administration in labo- mechanical ventilation was continued throughout the ratory experiments designed to mimic conditions com- study. Eight patients received an infusion of 4 mL/kg monly found during initial transport, evaluation, and re- of HSD over 30 minutes via central venous catheter. Eligible patients received HSD based on availability from suscitation of thermally injured patients. This work a 24-hour hospital pharmacy. Central hemodynamics confirmed that profound cardiac contractile dysfunc- were measured in all patients at the earliest possible tion exists for several days after cutaneous thermal in- time with a pulmonary artery catheter. jury and demonstrated the cardioprotective and volume- Fluid resuscitation of all patients was main- sparing effects of hypertonic saline when given immediately tained with RL in sufficient volume to maintain a urine after thermal injury as well as when given up to 4 hours output of 0.5 to 1.0 mL/kg per hour. Hemodynamic after injury.12 Given these findings and observations, we response to resuscitation was monitored by continu- proposed that a hypertonic saline bolus delivered within ous assessment of heart rate, blood pressure, and urine hours after thermal injury would benefit a patient popu- output. Measurements were made at 4-hour inter- lation expected to require massive fluid resuscitation and vals of cardiac output, central venous pressure, pul- monary capillary wedge pressure, and systemic vas- develop burn-related cardiac dysfunction. cular resistance. Hemodynamic, metabolic (serum In the present study, fluid resuscitation using lac- electrolytes, osmolality), and coagulation (prothrom- tated Ringer (RL) solution was initiated according to the bin time, partial thromboplastin time, platelet count) Parkland formula (4 mL/kg per each 1% total body sur- parameters were regularly measured for 24 hours. Ar- face area [TBSA] burned) in all patients with severe ther- terial blood was collected for measurement of PO2, mal injury. An HSD bolus was subsequently administered PCO2, and pH as clinically indicated. At the end of 8 on arrival to all patients who met the inclusion criteria. A and 24 hours, total fluid requirements and urine out- primary objective of this clinical study was to evaluate puts were calculated. In addition, venous blood the efficacy of an intravenous HSD bolus in maintaining samples were collected at regular intervals for the mea- cardiohemodynamic parameters and reducing resuscita- surement of serum troponin I, creatine kinase, and creatine kinase MB fraction levels to assess cardiac tion volume requirements when given as a supplement to injury. standard resuscitation fluid in acute thermal injury. Statistical significance was determined with an unpaired t test, with P,.05 representing significant RESULTS difference compared with patients receiving RL re- suscitation only. Analysis of variance was used to de- PATIENT PROFILE termine significance among multiple groups. The patient population studied (Table) was predomi- nantly men in the fourth decade of life who sustained a severe (.40% TBSA) thermal injury with comparable ex- (4 mL/kg) of 7.5% sodium chloride in 6% dextran-70 (HSD) tent of full-thickness injury. All patients survived through given early during resuscitation after several types of trauma the 24-hour study period. improved cardiac function and significantly reduced to- tal fluid requirements.3,10-12 Hypertonic solutions may re- RESUSCITATION VOLUME AND URINE OUTPUT duce resuscitation fluid volumes by osmotically drawing intracellular water into the depleted extracellular spaces, The total volume of resuscitation
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