DYNAMICS OF OSMOLARITY AND ELECTROLYTIC STRUCTURE OF BLOOD PLASMA IN PATIENTS WITH TRAUMATIC SHOCK DURING DELIVERY OF VARIOUS OPTIONS OF INFUSION THERAPY
Emergency Aid Station,
Kabanov City Clinical Hospital #1,
Omsk State Medical University, Omsk, Russia
Colloid and crystalloid solutions for infusion therapy in patients with traumatic shock should efficiently remove disorders of systemic hemodynamics and capillary circulation [1], as well as make minimal influence on other parameters of homeostasis [2]. The objective of the study was to research the dynamics of values of osmolarity and electrolytic composition of blood plasma in patients with traumatic shock of degree 3 in use of various options of volemic replacement.
MATERIALS AND METHODS
The study included 50 patients with traumatic shock of degree 3 who were distributed into two groups in dependence on the type of infusion therapy at prehospital and hospital stages of treatment (table 1).
| Table 1 | |||||||||||
| Sex and age composition, location of injuries, deficiency of CBV and degrees of shock in the patients of the groups I and II | |||||||||||
The inclusion criteria were: 1) age of the patients from 18 to 40; 2) acute initiation of the disease; 3) absence of narcotic or alcohol intoxication; 4) admission to the medical prophylactic institution within the first hour after development of the disease. The exclusion criteria were: 1) concurrent sub- or decompensated chronic renal pathologic states of the kidneys, the liver, the heart and the lungs; 2) history of oncologic pathology; 3) history of hormonal or chemical therapy; 4) diabetes mellitus of types 1 and 2; 5) terminal state; 6) participation in other study; 7) allergic responses to colloid solutions of hemodynamic type on the basis of 4 % modified gelatin (MG).
At the prehospital stage (before infusion therapy), traumatic shock was diagnosed on the basis of the following signs (considering history of previous injuries): level of consciousness (Glasgow Coma Scale ≤ 9), paleness and coldness of skin surface, mean arterial pressure (< 35 mm Hg) and shock index (2.9 and more). At the prehospital stage all patients received multimodal analgesia (narcotic or non-narcotic analgetics), infusion therapy with central venous (subclavicular or jugular veins) catheter and inotropic or vascular support with dopamine (5 µg/kg/min). After tracheal intubation all patients received artificial lung ventilation (Chirolog Paravent PAT, Chirana, Slovakia). Infusion therapy for the group 1 (25 patients) was conducted with non-balanced crystalloid solution of 0.9 % natrium chloride and colloid solution of 4 % modified gelatin (MG), for the patients of the group 2 (n = 25) – with balanced crystalloid solution of isotonic sterofundin and colloid solution of 4 % MG. The ratio of crystalloid and colloid solutions in the infusion therapy program was 1:3. The volume of prehospital and hospital blood loss was determined on the basis of shock index, clinical symptoms and estimated volume of external blood loss. The general volume of blood loss in the patients of the group 1 in the first day was 3,447.7 ± 231.1 ml, in the group 2 – 3,431.6 ± 212.3 ml. The general volume of transfused infusion-transfusion media was 9,987.4 ± 111.5 ml in the group 1, and 9,979.6 ± 109.5 ml in the group 2. The volume of infused colloid solutions was 3,246.3 ± 97.1 ml in the group 1, and 3,301.2 ± 92.8 ml in the group 2. The volume of infused crystalloid solutions was 1,265.2 ± 48.6 in the group 1, and 1,245.4 ± 56.7 ml in the group 2. Within the first 24 hours, replacement therapy for anemia and consumption coagulopathy was conducted in all patients according to the generally accepted criteria with use of transfusion of fresh frozen single-group plasma and packed red blood cells [3]. Within next two days transfusion therapy was realized on the basis of the results of the parameters of coagulation hemostasis, hemoglobin and hematocrit. The time from the moment of initiation of anti-shock measures to admission to the hospital was 56.9 min ± 0.4 min in the group 1, and 56.7 ± 0.3 min in the group 2. At the hospital stages all patients were immediately delivered to the surgery room for emergency surgical treatment with continuation of anti-shock therapy initiated at the prehospital stage, as well as for diagnostic examinations (plain x-ray imaging of the chest, abdominal cavity, cranial bones, pelvis and injured extremities, ultrasonic abdominal examination, laparoscopy, biochemical data, hemostasis parameters, clinical urine and blood analysis, estimation of blood group and Rh factor). Surgical treatment was accompanied by total intravenous anesthesia (fentanyl + ketamine + sibazon) with muscle relaxants in conditions of ALV with air-oxygen mixture. Surgical treatment was conducted for all patients (n = 50), and its volume depended location of the injury (table 1). Surgical treatment for the patients of the group 1 was initiated after 8.6 ± 1.1 min, for the group 2 – after 8.8 ± 1.3 min. After surgery all patients were admitted to the intensive care unit for initiation of infusion, antibacterial, respiratory and symptomatic therapy. The complex Diamant-R (Russia) was used for estimation of the parameters of cardiovascular system (stroke volume, [SV, ml]), cardiac output (CO, l), cardiac index (CI, l/min/m2), volume of plasma circulation (VPC, l), volume of circulating erythrocytes (VCE, l) by means of non-invasive tetrapolar rheography and impedancemetry. The hemodynamic monitor ICARD (Chirana, Slovakia) was used for estimation of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), MAP, HR and body temperature (T, °C). The parameters of plasma hemostasis (activated partial thromboplastin time [APTT] and soluble fibrin monomer complexes [SFMC]) were determined for dynamic estimation of intensity of coagulopathy and efficiency of its correction with transfusion therapy. The automatic hematologic analyzer Hemolux 19 (Mindray, China) was used for estimation of hematocrit, levels of red blood cells and hemoglobin. The level of lactate in the serum of venous blood was estimated with the biochemical analyzer Huma Laser 2000 (Human, Germany). The analyzer Easy Lyte (Medica, USA) was used for estimation of electrolytic composition of the serum of venous blood (levels of ions of potassium, natrium, chloride, ionized calcium [mmol/l]). The device MT-5 (Research and Production Enterprise “Burevestnik”, Russia) was used for estimation of osmolarity (mOsm/l) of blood and urea plasma. The studies were conducted after admission to ICU, 12 hours later, and within next 3 days. The systemic analysis was conducted with Statistica 6 (StatSoft, USA, 1999). The statistical hypotheses were tested with Wilcoxon’ test (comparison of two dependent samples), Mann-Whitney test (comparison of two independent samples) and ANOVA (comparison of more than two dependent samples). Spearman’s test was used for estimation of relationship between the variables. The null hypotheses was rejected, if p < 0.05 [4].
The study was conducted on the basis of the approval from the bioethical committee of Kabanov City Clinical Hospital #1. The study corresponded to the ethical standards of Helsinki declare – the Ethical Principles for Medical Research with Human Subjects 2000, and the Rules for Clinical Practice in Russian Federation confirmed by the order by Health Ministry of Russian Federation, June, 19, 2003, #266.
RESULTS
At the moment of admission the severity of general condition of the patients in the groups 1 and 2 was conditioned by traumatic shock of degree 3. It was confirmed by the results of systemic hemodynamics, lactate, diuresis, hematocrit, amount of red blood cells and level of hemoglobin (table 2). Upon admission all patients demonstrated the hypodynamic type of circulation according to the data of cardiac output, which was supported by means of intense tachycardia and vascular spasm (table 2).
| Table 2 | ||||||||||||||||||||||
| The results of comparative analysis of values of systemic hemodynamics, hemostasis, hematological and biochemical data in the patients of the groups I and II during treatment process (Me (Ql; Qh) - median (upper and lower quartiles)) | ||||||||||||||||||||||
| Note. * - statistically significant differences between values at admission and over time in 12 hours. |
The leading factor of decreased minute volume of blood circulation was deficiency of total volume of circulating blood. At the moment of admission the patients demonstrated some intense disorders of plasma hemostasis (table 2), which were conditioned by acute massive blood loss [5]. Upon admission to ICU the patients of the groups 1 and 2 did not show any statistically significant differences between the values of systemic hemodynamics, hemostasis, hematologic, biochemical and hemostasiological parameters (table 2). Already in 12 hours, intensive care made positive influence on the parameters of systemic hemodynamics and volemic status of the patients of the groups 1 and 2 (table 2). Efficient correction of circulating blood volume and the parameters of central hemodynamics conditioned improvement in peripheral circulation according to the data of lactate and diuresis (table 3, 4). It favored regression of shock and cancel of inotropic and vascular support in the patients of the groups 1 and 2 in the end of the second day. The positive statistically significant dynamics of urine osmolarity (table 3, 4) testified the efficient elimination of volemic disorders in the patients of the groups 1 and 2 (tables 3, 4). Also it was confirmed by the correlation analysis, which identified the reliable relationship between urine osmolarity and circulating blood volume in the patients of the groups 1 and 2 (r = -0.43, p = 0.048; r = -0.41, p = 0.047 correspondingly). Efficient elimination of hemocirculatory disorders by means of infusion-transfusion therapy favored the positive statistically significant dynamics of cardiac output during the whole period of observation (tables 3, 4). There were not any negative time trends of hemostasis parameters during the whole period of the follow-up (tables 3, 4).
| Table 3 | |||||||||||||||||
| Dynamics of values of systemic hemodynamics, hemostasis, hematological and biochemical data in the patients of the group I during treatment process (Me (Ql; Qh) - median (upper and lower quartiles)) | |||||||||||||||||
| Note. The tables 2 and 3: * - statistically significant differences in comparison with the previous period of treatment, with p < 0.05 (Wilcoxon test for two dependent samples), # - statistically significant changes of the value within 3 days of treatment, with p < 0.05 (ANOVA and Friedman test for multiple comparison of dependent samples). |
Table 4
| Dynamics of values of systemic hemodynamics, hemostasis, hematological and biochemical data in the patients of the group II during treatment process (Me (Ql; Qh) - median (upper and lower quartiles)) |
Already from the moment of admission to ICU the patients of the group 1 demonstrated the significant difference in the levels of calcium ions in comparison with the group 2 (the figure). However decreasing levels of ionized calcium did not influence on plasma hemostasis in the group 1. It was testified by the comparative analysis, which did not find any significant differences in the examined parameters of plasma hemostasis in the patients of the group 1 in comparison with the group 2 (tables 3, 4). Therefore, colloid solution of 4 % MG as a part of infusion therapy exerted only minimal influence on the parameters of plasma hemostasis in traumatic shock of degree 3.
Beginning from the second day, the patients of the group 1 showed the significant increase in the serum levels of natrium and chloride ions (the figure) in comparison with the identical data in the group 2. Increasing plasma levels of natrium ions conditioned the increase of plasma osmolarity in the patients of the group 1 in comparison with the similar values in the group 2 (the figure). The dependence of plasma osmolarity on the levels of natrium ions was confirmed by the identified statistically significant relationship (r = -0.46; p = 0.04). It was interesting that the higher level of urine osmolarity in the group 1 was found at the background of almost similar positive time trends of the values of central hemodynamics, volemic status and diuresis (tables 3, 4). Moreover, the patients of the group 1 showed the statistically significant decrease in the plasma levels of potassium ions (Fig. 1) in comparison with the similar data of the group 2. Normalizing plasma levels of the examined ions appeared later in the group 1 (the figure).
DISCUSSION
The positive statistically significant time course of the values of systemic hemodynamics and the marker of tissue hypoperfusion was accompanied by improving tissue perfusion and regressing metabolic disorders in the patients of the groups 1 and 2 at the background of various types of volemic replacement. Moreover, it conditioned the decrease in ischemic and hypoxic injuries to the organs and the systems [6].
At the same time, considering effective correction of cardiovascular insufficiency, the studied programs of infusion therapy exerted widely different influence on osmolarity and electrolytic composition of the blood plasma in the groups 1 and 2.
It is evident that in contrast to the patients of the group 1, the patients of the group 2 did not show any statistically significant changes in osmolarity and electrolytic composition of the blood plasma. According to our opinion, it was possible owing to the balanced crystalloid solution of isotonic sterofundin as a part of infusion therapy. It was associated with the fact that the solution of isotonic sterofundin (in contrast to 0.9 % sodium chloride) had the electrolytic and physiologic acid base composition corresponding to the blood plasma [7]. Such properties of isotonic sterofundin prevented increasing serum levels of natrium and chloride ions and decreasing levels of potassium and calcium ions within the whole period of observation in the patients of the group 2 in comparison with the group 1.
Disorders of electrolytic composition of the blood plasma are exceedingly important for critically ill patients [8]. Thus, increasing plasma levels of natrium ions determines increase of its osmolarity and development of negative changes of homeostasis and metabolism as result of disarranged functioning of the membrane potential of the cells [9].
In its turn, increasing plasma levels of chloride ions stimulate risk of hyperchloremia of extracellular space, renal angiospasm (resulting in decreasing diuresis and excessive hydration), as well as development of hyperchloremic metabolic acidosis [10]. Moreover, increasing plasma levels of chloride is one of the factors of increased vascular permeability [11] and relative hypovolemia [12].
It is important to note that decreasing plasma levels of calcium ions (calcium participates in all stages of coagulation hemostasis) determine the inadequacy of behavior of blood clotting processes [13], especially in patients with compromised hemostasis as result of massive blood loss [5].
CONCLUSION
1. In contrast to isotonic sterofundin, usage of 0.9 % natrium chloride as a part of infusion therapy for patients with traumatic shock of degree 3 causes some statistically significant changes of osmolarity and the electrolytic composition of the blood plasma, particularly, increasing osmolarity and increasing levels of natrium and chloride ions, as well as decrease in levels of ions of potassium and ionized calcium.
2. It is appropriately and justifiably to use infusion therapy with isotonic sterofundin and colloid solution of 4 % MG for patients with traumatic shock of degree 3.