Prehospital Hypertonic Saline/Dextran Infusion for Post-traumatic Hypotension The U.S.A. Multicenter Trial

Abstract

The safety and efficacy of 7.5% sodium chloride in 6% dextran 70 (HSD) in posttraumatic hypotension was evaluated in Houston, Denver, and Milwaukee. Multicentered, blinded, prospective randomized studies were developed comparing 250 mL of HSD versus 250 mL of normal crystalloid solution administered before routine prehospital and emergency center resuscitation. During a 13-month period, 422 patients were enrolled, 211 of whom subsequently underwent operative procedures. Three hundred fifty-nine patients met criteria for efficacy analysis, 51% of whom were in the HSD group. Seventy-two per cent of all patients were victims of penetrating trauma. The mean injury severity score (19), Trauma Score plus Injury Severity Score (TRISS) probability of survival, revised trauma scores (5.9), age, ambulance times, preinfusion blood pressure, and etiology distribution were identical between groups. The total amount of fluid administered, white blood cell count, arterial blood gases, potassium, or bicarbonate also were identical between groups. The HSD group had an improved blood pressure (p = 0.024). Hematocrit, sodium chloride, and osmolality levels were significantly elevated in the Emergency Center. Although no difference in overall survival was demonstrated, the HSD group requiring surgery did have a better survival (p = 0.02), with some variance among centers. The HSD group had fewer complications that the standard treatment group (7 versus 24). A greater incidence of adult respiratory distress syndrome, renal failure, and coagulopathy occurred in the standard treatment group. No anaphylactoid nor Dextran-related coagulopathies occurred in the HSD group. Although this trial demonstrated trends supportive of HSD in hypotensive hemorrhagic shock patients requiring surgery, a larger sample size will be required to establish which subgroups of trauma patients might maximally benefit from the prehospital use of a small volume of hyperosmolar solution. This study demonstrates the safety of administering 250 mL 7.5% HDS to this group of patients.

Hypertonic/hyperoncotic solution in hypovolemic patients: experience in the emergency room

“…Although we observed a clear difference in the volumes infused and in the hemodynamic stability associated with the hypertonic infusion, we did not observe any influence on complication rates in our patients in any group. Other studies have not shown any significant differences in overall complication rates in patients that received hyperosmotic solutions 15 . Although the differences were not significant, we observed more frequent complications directly related to shock and hypovolemia (renal, cardiac, and pulmonary complications) in the IS patients, while the patients in the HSD group presented more infectious and neurological complications.…”

Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials

“…11 Recently, hypertonic saline solutions have been suggested as the preferred solution in traumatic brain injury due to their volume repletion properties and their osmotic effect. 6 Hypertonic saline solutions are also considered an alternative in hypotensive trauma patients because of their volume expansion properties, 12 leading to their increased usage, when compared to mannitol, for the management of intracranial pressure. [13][14][15] Six systematic reviews aiming to evaluate the effect of hypertonic saline in neurocritically ill patients have been published showing inconsistent results.…”

Role of permissive hypotension, hypertonic resuscitation and the global increased permeability syndrome in patients with severe hemorrhage: adjuncts to damage control resuscitation to prevent intra-abdominal hypertension

“…Mattox et al [63] was the first in the USA to conduct a multicentre trial to compare hypertonic saline with dextran (HSD) to standard resuscitation. Their study demonstrated that HSD was safe, with lower incidence of ARDS, renal failure, and coagulopathy, but was not able to demonstrate a difference in overall survival due to insufficient sample size [63]. In 1997, Wade et al [64,65] conducted a meta-analysis of controlled clinical studies which showed an increased survival of HSD over 0.9% NSS in 7/8 clinical trials [64,65].…”