Critical Care Medicine

Adult Critical Care

Alternative Fluids for Prehospital Resuscitation: “Pharmacological” Resuscitation Fluids

Cotton BA (Univ of Texas Health Science Ctr at Houston) J Trauma 70:S30-S31, 2011^§

Abstract

Background

Injured patients with severe hemorrhage often receive immediate resuscitation using intravenous fluids and blood products to boost blood pressure. Rapid replacement of large fluid volumes, however, increases hemorrhage volume and lowers survival compared to low-volume or delayed fluid replacement. Apparently, inadequate tissue perfusion produces gross metabolic disorders, mitochrondrial dysfunction and energy failure, severe acidosis, and free radical generation plus the consumption of endogenous antioxidants. To prevent or reduce shock-related damage, novel agents that maintain intracellular and extracellular status during active resuscitation but require no large fluid volumes have been proposed. These include pyruvate, sodium ion/hydrogen ion exchange (NHE) inhibitors, valproic acid, and dihydroepiandrosterone (DHEA). The qualities of these various “pharmacological” resuscitative fluids were evaluated.

Pyruvate

Structurally similar to lactate but offering antioxidant and anti-inflammatory properties, pyruvate is associated with a survival benefit in hemorrhage but its use is limited by toxicity and instability. A stable lipophilic derivative, ethyl pyruvate, has been tested in animal models of hemorrhagic shock. In mice, adding ethyl pyruvate to conventional resuscitation fluids reduced tumor necrosis factor levels and improved survival, possibly because it is a reactive oxygen species scavenger. Hemorrhage-induced gut barrier dysfunction and hepatic lipid peroxidation were also reduced.

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