Resuscitation with Hydroxyethyl Starch Maintains Hemodynamic Coherence in Ovine Hemorrhagic ShockAnesthesiology 1 2020, Vol.132, 131-139. doi:https://doi.org/10.1097/ALN.0000000000002998
What We Already Know about This Topic:Both saline and hydroxyethyl starch can be used for fluid resuscitation of hemorrhagic shockHemodynamic coherence is the concordant performance of macro- and microcirculationIt is not known whether saline or hydroxyethyl starch resuscitation achieves better hemodynamic coherence
What This Article Tells Us That Is New:In a sheep model of hemorrhagic shock, resuscitation with both saline and hydroxyethyl starch restored mean arterial pressure (macrocirculation)After fluid resuscitation with hydroxyethyl starch, microcirculatory perfused vessel density and microvascular flow index (microcirculation) both improved, whereas saline only marginally improved microvascular flow index and perfused vessel density decreased furtherResuscitation with hydroxyethyl starch but not saline maintained hemodynamic coherence after hemorrhagic shock
Background: Fluid resuscitation in hemorrhagic shock aims to restore hemodynamics and repair altered microcirculation. Hemodynamic coherence is the concordant performance of macro- and microcirculation. The present study on fluid therapy in hemorrhagic shock hypothesized that the choice of fluid (0.9% sodium chloride [saline group] or balanced 6% hydroxyethyl starch 130/0.4 [hydroxyethyl starch group]) impacts on hemodynamic coherence.
Methods: After instrumentation, 10 sheep were bled up to 30 ml/kg body weight of blood stopping at a mean arterial pressure of 30 mmHg to establish hemorrhagic shock. To reestablish baseline mean arterial pressure, they received either saline or hydroxyethyl starch (each n = 5). Hemodynamic coherence was assessed by comparison of changes in mean arterial pressure and both perfused vessel density and microvascular flow index.
Results: Bleeding of 23 ml/kg blood [21; 30] (median [25th; 75th percentile]) in the saline group and 24 ml/kg [22; 25] (P = 0.916) in the hydroxyethyl starch group led to hemorrhagic shock. Fluid resuscitation reestablished baseline mean arterial pressure in all sheep of the hydroxyethyl starch group and in one sheep of the saline group. In the saline group 4,980 ml [3,312; 5,700] and in the hydroxyethyl starch group 610 ml [489; 615] of fluid were needed (P = 0.009). In hemorrhagic shock perfused vessel density (saline from 100% to 83% [49; 86]; hydroxyethyl starch from 100% to 74% [61; 80]) and microvascular flow index (saline from 3.1 [2.5; 3.3] to 2.0 [1.6; 2.3]; hydroxyethyl starch from 2.9 [2.9; 3.1] to 2.5 [2.3; 2.7]) decreased in both groups. After resuscitation both variables improved in the hydroxyethyl starch group (perfused vessel density: 125% [120; 147]; microvascular flow index: 3.4 [3.2; 3.5]), whereas in the saline group perfused vessel density further decreased (64% [62; 79]) and microvascular flow index increased less than in the hydroxyethyl starch group (2.7 [2.4; 2.8]; both P < 0.001 for saline vs. hydroxyethyl starch).
Conclusions: Resuscitation with hydroxyethyl starch maintained coherence in hemorrhagic shock. In contrast, saline only improved macro- but not microcirculation. Hemodynamic coherence might be influenced by the choice of resuscitation fluid.
羥乙基澱粉復甦維持綿羊失血性休克中血流動力學一致性在失血性休克綿羊模型中，用生理鹽水和羥乙基澱粉復甦恢復了平均動脈壓（宏觀循環）
羥乙基澱粉液體復甦後，微循環血管密度和微血管流量指數（微循環）均有所改善，而生理鹽水僅微血管流量指數略有改善，灌注血管密度進一步降低
失血性休克後僅羥乙基澱粉而非鹽水復甦能維持血流動力學一致性
背景：失血性休克的液體復甦旨在恢復血流動力學，修復微循環改變。血流動力學一致性是宏觀和微觀循環的一致性表現。失血性休克液體治療的研究假設液體的選擇（0.9%氯化鈉[生理鹽水組]或平衡的6%羥乙基澱粉130/0.4[羥乙基澱粉組]）的選擇會影響血流動力學的一致性。
方法：10隻綿羊在器械固定後，以30mmhg的平均動脈壓停血30ml/kg體重建立失血性休克模型。為了恢復基礎平均動脈壓，他們接受生理鹽水或羥乙基澱粉（每個n=5）。通過比較平均動脈壓、灌注血管密度和微血管流量指數的變化來評估血流動力學一致性。
結果：生理鹽水組23ml/kg血[21；30]（中位[25；75百分位]）和羥乙基澱粉組24ml/kg血[22；25]（P=0.916）出血導致失血性休克。在羥乙基澱粉組的所有綿羊和生理鹽水組的一隻綿羊中，液體復甦恢復了基礎平均動脈壓。生理鹽水組需要4980毫升[3312；5700]和羥乙基澱粉組需要610毫升[489；615]液體（P=0.009）。失血性休克時，兩組灌流血管密度（生理鹽水從100%降至83%[49；86]；羥乙基澱粉從100%降至74%[61；80]）和微血管流量指數（生理鹽水從3.1[2.5；3.3]降至2.0[1.6；2.3]；羥乙基澱粉從2.9[2.9；3.1]降至2.5[2.3；2.7]）。復甦後，羥乙基澱粉組的兩個變量均有改善（灌流血管密度：125%[120；147]；微血管流量指數：3.4[3.2；3.5]），而生理鹽水組灌流血管密度進一步降低（64%[62；79]），微血管流量指數的增加低於羥乙基澱粉組（2.7[2.4；2.8]；生理鹽水和羥乙基澱粉均P<0.001）。
結論：羥乙基澱粉復甦在失血性休克中保持了血流動力學的一致性。相比之下，生理鹽水只能改善宏觀循環，但不能改善微循環。復甦液的選擇可能影響血流動力學的一致性。