Hypertonic sodium chloride solutions for the prehospital management of traumatic hemorrhagic shock: A possible improvement in the standard of care?

Acute hemorrhage is a major cause of death in both civilian and military trauma. The suboptimal effect of the volume of standard crystalloids that can be infused during transport has resulted in a need for a more efficacious fluid for the prehospital management of both civilian and military trauma. Markedly hypertonic sodium chloride solutions have been shown to improve transiently the hemodynamic consequences of shock in animal models. The use of small volumes of 7.5% NaCl in 6% dextran 70 has resulted in a solution superior to equal volumes of standard crystalloids in the ability to resuscitate animals from hemorrhagic shock. The hypertonic sodium chloride/dextran solution has the potential advantages of improving survival, producing a beneficial hemodynamic effect with smaller fluid volumes, reducing total fluid requirements during resuscitation, and being stored easily. This solution may prove valuable in the early resuscitation of the hypovolemic trauma patient and merits further clinical trials.     

Histamine antagonists in the treatment of shock hyperglycemia in the rat

The present study was undertaken to determine the effect of exogenous histamine and histamine blockers on blood glucose and hepatic glycogen in the rat. Forty-one nonfasted male Sprague-Dawley rats that had been anesthetized with intraperitoneal injections of urethane were injected intravenously (femoral) with histamine (10 mg/kg) five minutes after pretreatment with Ringer's solution (control), diphenhydramine (1 mg/kg) (H-1 blocker); metiamide (1 mg/kg) (H-2 blocker); or a combination of these blockers. Mean arterial pressure (carotid), blood glucose, and hepatic glycogen were measured. Within 30 minutes, histamine evoked a significant increase in blood glucose, and a decrease in hepatic glycogen, and a reduction in blood pressure. However, rats treated with the H-2 blocker metiamide or with a combination of H-1 and H-2 blockers did not show as significant a hypotensive response as rats treated with the H-1 blocker diphenhydramine alone. The hyperglycemic-glycogenolytic response to histamine was modified by diphenhydramine as well as by a combination of blockers, but not by metiamide alone. These results suggest that a) the hypotension did not initiate the hyperglycemic and glycogenolytic response; b) the H-2 blocker metiamide has little effect on the hyperglycemic response to exogenous histamine; and c) the H-1 blocker diphenhydramine may have antihyperglycemic properties.     

心血管内分泌学:内分泌医师面临的挑战

糖尿病与冠心病的联系已引起内分泌及心血管医师的广泛兴趣。然而,心血管的内分泌问题包括、但并非局限于糖尿病。心脏与血管本身也是内分泌器官,内分泌各系统的疾病又都与心血管的终点事件紧密相关。故心血管内分泌学,作为经典内分泌学的一个既特殊又共同的领域应运而生。我们内分泌医师在处理内分泌代谢病的第一线,位于心血管疾病的上游,密切关注与深入研究心血管内分泌学已责无旁贷。     

Hemodynamic effects of pneumatic external counterpressure in canine hemorrhagic shock

To assess the effects of external counterpressure in a hypovolemic canine model, mean right atrial pressure (RA), left ventricle end-diastolic pressure (LVEDP), mean aortic pressure (Ao), and cardiac output (CO) (indicator dilution technique or electromagnetic ascending aortic flow) were measured in eight closed-chest mongrel dogs following phlebotomy to an Ao of 50 to 60 mm Hg. Inferior vena cava (IVC) flow was measured electromagnetically with a cannulating probe in four animals. The antishock garment was inflated to pressures of 40, 60, 80, and 100 mm Hg. An extended shock "control" period preceded inflation to minimize the effect of reflex circulatory responses to acute blood loss. IVC flow (2 +/- 1 mL/min/kg) during and immediately following antishock garment inflation was not significantly different from control (3 +/- 1 mL/min/kg) regardless of inflation pressure. Ao, RA, and LVEDP measured 30 seconds and 15 minutes after garment inflation were increased, but CO was not significantly different from control values at each inflation pressure. Garment inflation significantly increased peripheral vascular resistance (PVR) at all inflation pressures, and there was a significant correlation (r = .53; P less than .001) between the change in Ao and PVR. These results indicate that the change in arterial pressure produced by external counterpressure is the result of an increase in PVR and not the result of an autotransfusion and subsequent increased left heart outflow in the canine shock model.     

Control of intraabdominal hemorrhage and shock: a comparison of fluid resuscitation, MAST, and balloon occlusion

Our study examined the efficacy of four treatment modalities in controlling hemorrhage and achieving hemodynamic stabilization in hemorrhagic shock: intravenous fluid replacement (IV); military antishock trousers used concomitantly with fluids (MAST); balloon occlusion at the level of the diaphragm with concomitant fluid replacement (balloon); and a combination of MAST inflation, balloon occlusion, and fluid resuscitation (MAST and balloon). Twenty-eight mongrel dogs were anesthetized, and the spleen was exposed and completely crushed. The abdomen was closed, and treatment was initiated and continued for four hours or until the dog died. For all conditions the hematocrit dropped during the course of the experiment; balloon occlusion was effective at slowing this drop (P less than .0001), but MAST had no statistically significant effect. Animals with balloons bled more slowly into the abdominal cavity than did animals in the other two groups (P less than .0001). MAST also were effective at slowing the bleeding (P less than .05). Of the balloon and the MAST and balloon dogs, all except one survived the entire four hours; this difference between balloon and nonballoon dogs is significant (P = .002). MAST did not have a statistically significant effect on survival. Perfusion pressure (PP) declined during the course of the experiment, and the balloon was effective at slowing this decline (P less than .0001); none of the other comparisons was statistically significant.     

垂体后叶素治疗肠源性脓毒性休克的临床研究

目的探讨垂体后叶素对肠源性脓毒性休克患者的临床价值。方法入选2013年6月至2017年3月期间南通市第三人民医院重症医学科连续收治的肠源性脓毒性休克患者64例,随机数字表法分为常规组和垂体后叶素组,其中常规组30例,垂体后叶素组34例。根据2012年国际脓毒症救治指南实施救治,常规组使用去甲肾上腺素3 mg以生理盐水配制成50 ml溶液,单独经深静脉导管泵入。垂体后叶素组在上述治疗基础上加用垂体后叶素24 U以生理盐水配制成48 ml溶液,以0.5~2.0 U/h速度经深静脉导管泵入。收集两组患者入科时及治疗24 h后的心率(HR)、平均动脉压(MAP)、腹内压(IAP)、去甲肾上腺素用量、白细胞(WBC)、血小板(PLT)、乳酸(Lac)、总胆红素(TBIL)、血肌酐(SCr)、空腹血糖(FBG)、氧合指数(OI)、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和序贯器官衰竭估计评分(SOFA)以及28 d病死率。计量资料用均数±标准差(x±s)表示,两组比较采用t检验,多组比较采用单因素方差分析。计数资料用百分率表示,组间比较采用x~2检验或Fisher确切概率法。结果两组患者治疗前HR、MAP、IAP、WBC、PLT、Lac、TBIL、SCr、FBG、OI、去甲肾上腺素用量、APACHEⅡ评分及SOFA评分等差异无统计学意义(P0.05)。相比治疗前,治疗24 h后常规组HR及去甲肾上腺素用量增加,WBC、FBG及SOFA评分下降,垂体后叶素组HR、IAP、WBC、FBG、Lac、去甲肾上腺素用量及SOFA评分下降,差异有统计学意义(P0.05)。治疗24 h后,垂体后叶素组患者的HR、Lac、IAP及去甲肾上腺素用量明显低于常规组,差异有统计学意义(P0.05),其OI高于常规组,但差异无统计学意义(P=0.066)。常规组和垂体后叶素组的28 d病死率分别为46.66%和35.29%,差异无统计学意义(P=0.355)。结论联合使用垂体后叶素可显著减少肠源性脓毒性休克患者的去甲肾上腺素用量,减慢心率,有助于降低IAP及Lac水平,具有较好的临床应用价值。     

Rapid flow rates for the resuscitation of hypovolemic shock

Nine dogs were hemorrhaged to approximately 40% of their blood volume and then were resuscitated with a crystalloid solution (Normosol) at various flow rates. Three study groups with three dogs in each group were resuscitated at 15 mL/min/kg (Group 1), 6 mL/min/kg (Group 2), and 4 mL/min/kg (Group 3). Central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), mean arterial pressure, and cardiac output (CO) were monitored during the hemorrhage and the resuscitation from shock. During the infusion of fluids, Group 1 animals demonstrated an elevation of the PAWP of 31 mm Hg and elevation of CVP to 23.2 mm Hg; CO rose to 8.4 L/min. In Group 2 animals CO rose to 6.1 L/min; CVP was 10.5 mm Hg; and PAWP was 25 mm Hg. Group 3 animals had a rise in CO to 5 L/min; CVP and PAWP rose to 4.5 mm Hg and 6.8 mm Hg, respectively. In this experimental shock study, infusion of crystalloids at 6 mL/min/kg appeared to result in an improved physiologic response, although no statistical difference was demonstrated. Further studies are necessary to demonstrate the optimum flow rate for resuscitation of hypovolemic shock using crystalloids.     

The Impact of the CEDD-NET on the Evaluation of Rare Disorders: A Multicenter Scientific Research Platform in the Field of Pediatric Endocrinology

Objective:The database http://cedd.saglik-network.org (CEDD-NET) has been operating since 2013 in Turkey. All pediatric endocrinologists can propose projects to this network. The aim of our study was to determine the impact of CEDD-NET on the transformation of multicenter studies into scientific publications and assess the academic characteristics of the studies that have been transcribed into publication.Methods:All the studies that were opened to patient admission on the website between August 26, 2013 and March 1, 2021 were reviewed.Results:A total of 30 studies were accepted and opened for data entry. The median data collection period was 12 (1.5-24) months, while the median number of researchers participated was 23 (3-180), the median number of cases was 120 (26-192). The average cost was $2113 (1370-3118). Out of 30 studies, data entry was completed for 27. Sixteen publications were produced from 14 studies, 13 ot them have not published yet. The median time from the end of data entry to publication of the study was 686 (168-1608) days. While the median impact factor of the journals in which the studies were published was 1.803 (1.278-5.399), the median number of citations was 6.5 (0-49), and cited by 99 times in Web of Science indexed journals in total.Conclusion:CEDD-NET appears to be productive and effective as all the publications are of high quality that have been published in the Q1-Q2 categories. This study demonstrated the benefits and necessity of establishing nationwide databases, even covering more than one country, in specialized branches, such as pediatric endocrinology where rare diseases are of concern.     

热休克蛋白90家族异常表达与肝细胞癌变关系的研究进展

热休克蛋白（heat shock proteins,HSPs）又称应激蛋白,是机体细胞在一些应激原诱导下激活HSP基因,高效表达的具有高度保守性质的一组蛋白质,与多种蛋白形成复合体,陪伴蛋白分子在细胞内转运、跨膜,参与蛋白的折叠与伸展、多聚复合体的组装,发挥其调节靶蛋白的作用,但又不改变靶蛋白的结构,故被称为＂分子伴侣＂（Molecular Chaperone）.HSP90及gP96在肝癌（HCC）组织中表达异常,抑制细胞凋亡,与肝癌发生、发展及其预后关系密切.     

Coagulation abnormalities in traumatic shock

Coagulation abnormalities can pose a threat to hemorrhaging patients and to attempts at surgical correction. We have shown that 97.2% of our 180 patients who died of trauma had evidence of coagulation defects prior to fluid or blood treatment. Twelve of 180 patients could not be cross-matched due to inability of their blood to coagulate in the tube. Clinically 50% of these patients had excessive oozing from venipuncture sites, and 28% had excessive hematoma formation not associated with vascular injury. The most frequently abnormal test was the prothrombin time, in 97% of patients followed by platelet count in 72%, and partial thromboplastin time in 70%. The greatest degree of coagulation abnormality occurred in patients with head trauma, followed in decreasing order by gunshot wounds, blunt trauma, and stab wounds to the body. Because 97.2% of the patients had abnormal coagulation studies prior to fluid and blood replacement, this abnormality most likely was due to disseminated intravascular coagulation. We propose using the tube-clot test to give a rapid indication of coagulation in traumatized patients while awaiting laboratory test results.     

The effect of steroid administration on pancreatic secretion during and after hypovolemic shock

Summary In a previous report from this laboratory, 1 h of hypovolemia induced a significant decrease in pancreatic flow, bicarbonate and enzyme secretion. These parameters recover after restoration of blood volume, but never return to pre-shock levels. Furthermore, increasing the period of hypovolemia produced further decreases in pancreatic flow and bicarbonate secretion only. Enzyme secretion, however, rose significantly, probably due to leakage of protein through damaged cell membranes. Prolonged hypovolemia was also accompanied by visible edema. This model of secretory changes induced by fixed periods of hypovolemic shock is ideal to study the effect of steroids on secretion and to assess its possible cytoprotective properties against early induced ischemia pancreatic pathology. Pancreatic secretion was collected by cannulation of the main pancreatic duct in 12 anesthetized dogs. Secretin was administered by continuous intravenous (i.v.) infusion at 4 U/kg/h. Four 15-min samples of pancreatic juice were collected. Then the dogs were bled, withdrawing 25–30% of total blood volume or until the mean blood pressure dropped to about 60 mmHg. At this point, 30 mg/kg of methyl prednisolone were given in 50 cm³ of NaCl i.v. to six animals. Blood samples for amylase and 15-min collections of pancreatic juice for volume, bicarbonate and enzymes were obtained during hypovolemia, as well as during and following the restoration of blood volume. The responses of the two groups differed as follows: (1) Instead of the increase in protein enzyme secretion seen in the non-steroid group with increased duration of hypovolemia, steroid-treated dogs displayed a significant decrease in protein output. (2) Serum amylase levels rose progressively in the non-steroid group and continued to increase after restoration of blood volume. In the steroid-treated animals, the amylase rise during hypovolemia was significantly less, and following restoration of blood volume, serum amylase actually decreased. This study demonstrates the beneficial effect of steroids on pancreatic secretion, during and after prolonged periods of hypovolemic shock. Reduced enzyme output and decreasing serum amylase levels are evidence of a stabilization of acinar and ductular cell membranes, an activity which augurs less severe resultant pathology and increased possibilities for recovery. These secretory effects would warrant a controlled clinical trial for steroids in treatment of human pancreatic inflammation.