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      Hypertonic saline and hemorrhagic shock: hepatocellular function and integrity after six hours of treatment Translated title: Solução salina hipertônica e choque hemorrágico: função hepatocelular e integridade após seis horas de tratamento

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          Abstract

          PEURPOSE: The comparison after 6h of hemorrhagic shock (HS) treatment with NaCl 7.5% (Hypertonic Saline Solution - SSH) or Ringer Lactate (RL) on liver function and integrity. METHODS: Male Wistar rats were submitted to HS (Mean Arterial Pressure - MAP= 45 mmHg) during 60 min and then treated with NaCl 7.5% (SSH, 10% of blood loss, n=8) or Ringer Lactate (RL, 400% of blood loss, n=8). After 6h rats were anesthetized, hepatic function was assessed by bile flow measurement and liver integrity evaluated by determination of alanine aminotransferase (ALT) and bilirubin activities. RESULTS: There was no difference in MAP between the groups during the whole experiments. Biliary flow showed a significant recovery after SSH treatment (p<0.05), and significant decrease of ALT (p<0.001) and bilirubin levels (p<0.001) in comparison to RL. CONCLUSION: Resuscitation of HS with NaCl 7.5% promoted better recovery of liver function and lesser hepatocellular damage after 6h of treatment compared to RL. The improvement is very likely related to increased microvascular perfusion provided by small volume resuscitation.

          Translated abstract

          OBJETIVO: Comparar os efeitos após 6 horas do tratamento do choque hemorrágico (CH) com solução de NaCl 7,5% (Solução Salina Hipertônica - SSH) e Ringer Lactato (RL) sobre a função e integridade hepática em ratos. MÉTODOS: Ratos Wistar (n=16) machos foram submetidos a choque hemorrágico controlado (Pressão Arterial Média - PAM = 45 mmHg) durante 60 minutos e após ressuscitados com SSH (10% da perda volêmica, n=8) ou RL (4 vezes o volume sangüíneo retirado, n=8). Após 6 horas a função hepática foi determinada pela quantificação do fluxo biliar. A integridade hepática foi avaliada pelas bilirrubinas e pela alanino aminotransferase (ALT). RESULTADOS: Não foi constatada diferença de PAM entre os grupos durante os experimentos. O fluxo biliar apresentou recuperação significativa no grupo SSH em comparação ao grupo RL (p<0,05). O grupo SSH apresentou diminuição significativa nos níveis de ALT (p<0,001) e das bilirrubinas (p<0,001). CONCLUSÃO: Após 6 horas de tratamento do choque hemorrágico a SSH mostrou-se superior ao RL, recuperando a função e a integridade hepatocelular, provavelmente por melhora da perfusão nutricional hepática, e diretamente relacionada ao seu mecanismo de ação.

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          Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions.

          The concept of small-volume resuscitation (SVR) using hypertonic solutions encompasses the rapid infusion of a small dose (4 ml per kg body weight, i.e. approximately 250 ml in an adult patient) of 7.2-7.5% NaCl/colloid solution. Originally, SVR was aimed for initial therapy of severe hypovolemia and shock associated with trauma. The present review focuses on the findings concerning the working mechanisms responsible for the rapid onset of the circulatory effect, the impact of the colloid component on microcirculatory resuscitation, and describes the indications for its application in the preclinical scenario as well as perioperatively and in intensive care medicine. With respect to the actual data base of clinical trials SVR seems to be superior to conventional volume therapy with regard to faster normalization of microvascular perfusion during shock phases and early resumption of organ function. Particularly patients with head trauma in association with systemic hypotension appear to benefit. Besides, potential indications for this concept include cardiac and cardiovascular surgery (attenuation of reperfusion injury during declamping phase) and burn injury. The review also describes disadvantages and potential adverse effects of SVR: Small-volume resuscitation by means of hypertonic NaCl/colloid solutions stands for one of the most innovative concepts for primary resuscitation from trauma and shock established in the past decade. Today the spectrum of potential indications involves not only prehospital trauma care, but also perioperative and intensive care therapy.
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            A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride. The effect of added dextran 70. The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients.

            To evaluate the use of 250 mL of a 7.5% sodium chloride solution, both with and without added dextran 70, for the prehospital resuscitation of hypotensive trauma patients. Double-blind randomized trial. Six trauma systems served by helicopter transport. Injured patients with systolic blood pressures less than 90 mm Hg at any time in the field or during helicopter transport. Infusion of study solution, in the field or during transport, followed by conventional isotonic solutions as needed. Solutions studied in four cohorts were as follows: (1) lactated Ringer's; (2) 7.5% sodium chloride (hypertonic saline); (3) 7.5% sodium chloride combined with 6% dextran 70; and (4) 7.5% sodium chloride combined with 12% dextran 70. Blood pressure response; survival to time of hospital discharge among the treatment groups; and survival compared with that predicted by norms from the Major Trauma Outcome Study (MTOS). The mean (+/- SD) change in systolic blood pressure on arrival in the emergency department was significantly higher in the hypertonic saline solution group than that in the lactated Ringer's solution group (34 +/- 46 vs 11 +/- 49 mm Hg, P < .03). Overall survival in the four treatment groups was 49%, 60%, 56%, and 45% (not statistically significant). Survival in the hypertonic saline solution group, however, was significantly higher than that predicted by the MTOS norms (60% vs 48%, P < .001). Survival to hospital discharge in patients with baseline Glasgow Coma Scale scores of 8 or less was correlated with treatment group (P < .05 by logistic regression and P < .01 by Cox proportional-hazards analysis; with survival in the hypertonic saline solution group [34%] vs lactated Ringer's solution group [12%]). Prehospital infusion of 250 mL of 7.5% sodium chloride is associated with an increase in blood pressure and an increase in survival to hospital discharge compared with survival predicted by the MTOS norms. Patients with low baseline Glasgow Coma Scale scores seem to benefit the most from 7.5% sodium chloride resuscitation. Hypertonic saline solution without added dextran 70 is as effective as the more expensive solutions that contain dextran 70.
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              Resuscitation with lactated Ringer's solution in rats with hemorrhagic shock induces immediate apoptosis.

              We hypothesize that different resuscitative fluids may immediately affect the degree of apoptosis after hemorrhagic shock. Rats (n = 35) were hemorrhaged 27 mL/kg over 5 minutes followed by 1 hour of shock, then resuscitation over 1 hour. The six treatment groups were sham hemorrhage, sham resuscitation, whole blood resuscitation, lactated Ringer's solution (LR) resuscitation with three times the volume bled, sham hemorrhage with LR infusion, and 7.5% hypertonic saline resuscitation (9.7 mL/kg). Liver and small intestine were harvested immediately after resuscitation. Apoptosis was evaluated by using in situ cell death detection method. Resuscitation with LR resulted in a significant increase in small intestinal and liver apoptosis. Animals that received LR infusion without hemorrhage had an increased level of apoptosis in the intestine. Apoptosis in the intestine was observed in both the mucosa and muscularis externa. There was no increase in apoptosis in either organ in the animals resuscitated with sham resuscitation, whole blood, and hypertonic saline compared with the sham hemorrhage group. Resuscitation with LR solution after hemorrhagic shock increased immediate cell death by apoptosis in both the small intestine and liver. There was no significant increase in apoptosis in the animals resuscitated with hypertonic saline, whole blood, or in unresuscitated animals. Thus, the type of resuscitation fluid used may affect the apoptotic cellular response to shock.
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                Author and article information

                Journal
                acb
                Acta Cirúrgica Brasileira
                Acta Cir. Bras.
                Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia (São Paulo, SP, Brazil )
                0102-8650
                1678-2674
                December 2005
                : 20
                : 6
                : 414-417
                Affiliations
                [01] Porto Alegre orgnameUFRGS Brazil
                [02] Porto Alegre orgnameUFRGS orgdiv1Department of Morphological Sciences Brazil
                [03] Criciúma Santa Catarina orgnameUniversidade do Extremo Sul Catarinense orgdiv1Experimental Physiopathology Laboratory Brazil
                Article
                S0102-86502005000600003 S0102-8650(05)02000603
                5b1aed4c-94da-47cf-9a22-df5d40de0660

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 20 May 2005
                : 19 July 2005
                : 15 June 2005
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 19, Pages: 4
                Product

                SciELO Brazil

                Categories
                Original Article

                Solução Salina Hipertônica,Fígado Ratos,Saline Solution,Rats,Liver,Hypertonic,Hemorrhagic,Shock,Reperfusion,Ischemia,Choque Hemorrágico,Reperfusão,Isquemia

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