Hemorrhagic shock: a review
1
396 Critical Care October 2004 Vol 8 No 5 Chapman I read with interest the review by Prof. Gutierrez and colleagues on hemorrhagic shock [1]. The treatment of hemorrhagic shock is addressed in the review, and mention is made of the main goals: to stop the source of hemorrhage and to restore the circulating volume. Conserving blood products, on the grounds of cost, restricted availability and their pathophysiological effects, is becoming a necessary shift in the approach to these difficult patients and was not touched upon in the review. There have been clear advances in recent years in developing other strategies to aggressively stem the flow. Damage control surgery in trauma and embolization are certainly useful tools in the control of bleeding. Pharmacological manipulation of the coagulation system is a rapidly expanding field of research. Activated recombinant factor VII (Factor VIIa) is a hemostatic agent originally developed for the hemophilia population, but it is emerging as a very effective way of treating uncontrolled hemorrhage in patients without pre-existing factor deficiencies. A hetero- geneous case series of major hemorrhage was reported last year, in which 80% of the cases given Factor VIIa responded with complete or partial cessation of bleeding [2]. Data from the trauma environment with massive bleeding suggest a useful role for Factor VIIa [3], and further studies are ongoing. Competing interests The author declares that he has no competing interests. Letter Hemorrhagic shock: a review Martin Chapman Assistant Professor, University of Toronto and Staff Intensivist, Sunnybrook and Women’s College Health Sciences Centre, Toronto, Canada Corresponding author: Martin Chapman, [email protected] Published online: 30 June 2004 Critical Care 2004, 8:396 (DOI 10.1186/cc2898) This article is online at http://ccforum.com/content/8/5/396 © 2004 BioMed Central Ltd See Review, page 373 Authors’ response H David Reines, Marian Wulf-Gutierrrez and Guillermo Gutierrez We thank Dr Chapman for his comments on new approaches to control hemorrhage. We agree that conservation of blood and blood products is not just an economic concern, but it is necessary to protect a limited resource and to prevent untoward effects of such products. Our sections on hypertonic saline and the use of blood substitutes were meant to address this issue directly. We limited our discussion to a general discussion of hemorrhagic shock and did not specifically address surgical approaches to the control of bleeding. ‘Damage control’ and packing is a valid concept in the treatment of severely injured patients with hemorrhage [4]. This approach was frequently used in battlefields, and has become more popular in civilian injury as a method for preventing death from coagulopathy and hypothermia in the operating room. The use of radiological embolization as a technique to control ongoing hemorrhage from solid organs such as the spleen and the liver has also supplemented its use in pelvic hemorrhage. This technique is not necessarily an ideal therapy for patients who are in shock. Operative intervention is still necessary in unstable patients. We agree that pharmacological manipulation may be an adjunct to good surgical practice. There are anecdotal reports on the use of activated recombinant factor VII to control bleeding in trauma patients, as well as in numerous other patient populations who do not have hemophilia. The unencumbered use of this extremely expensive treatment has led to the loss of millions of dollars in uncompensated care and occasional significant complications. The present status of this potentially important addition to the armamentarium is under investigation. Prospective studies need to be performed to establish efficacy and criteria for use before we embark on this new approach. Competing interests The authors declare that they have no competing interests. References 1. Gutierrez G, Reines HD, Wulf-Gutierrez M: Clinical review: Hem- orrhagic shock. Crit Care 2004, 8:373-381. 2. O’Connell NM, Perry DJ, Hodgson AJ, O’Shaughnessy DF, Laffan MA, Smith OP: Recombinant FVIIa in the management of uncontrolled hemorrhage [see comment]. Transfusion 2003, 43:1711-1716. 3. Dutton RP, Hess JR, Scalea TM: Recombinant factor VIIa for control of hemorrhage: early experience in critically ill trauma patients. J Clin Anesth 2003, 15:184-188. 4. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, Latenser BA, Angood PA: ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993, 35:375-382.
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Transcript of Hemorrhagic shock: a review
396
Critical Care October 2004 Vol 8 No 5 Chapman
I read with interest the review by Prof. Gutierrez andcolleagues on hemorrhagic shock [1]. The treatment ofhemorrhagic shock is addressed in the review, and mention ismade of the main goals: to stop the source of hemorrhageand to restore the circulating volume. Conserving bloodproducts, on the grounds of cost, restricted availability andtheir pathophysiological effects, is becoming a necessary shiftin the approach to these difficult patients and was nottouched upon in the review. There have been clear advancesin recent years in developing other strategies to aggressivelystem the flow.
Damage control surgery in trauma and embolization arecertainly useful tools in the control of bleeding.
Pharmacological manipulation of the coagulation system is arapidly expanding field of research. Activated recombinantfactor VII (Factor VIIa) is a hemostatic agent originallydeveloped for the hemophilia population, but it is emerging asa very effective way of treating uncontrolled hemorrhage inpatients without pre-existing factor deficiencies. A hetero-geneous case series of major hemorrhage was reported lastyear, in which 80% of the cases given Factor VIIa respondedwith complete or partial cessation of bleeding [2]. Data fromthe trauma environment with massive bleeding suggest auseful role for Factor VIIa [3], and further studies are ongoing.
Competing interestsThe author declares that he has no competing interests.
LetterHemorrhagic shock: a reviewMartin Chapman
Assistant Professor, University of Toronto and Staff Intensivist, Sunnybrook and Women’s College Health Sciences Centre, Toronto, Canada
Corresponding author: Martin Chapman, [email protected]
Published online: 30 June 2004 Critical Care 2004, 8:396 (DOI 10.1186/cc2898)This article is online at http://ccforum.com/content/8/5/396© 2004 BioMed Central Ltd See Review, page 373
Authors’ responseH David Reines, Marian Wulf-Gutierrrez and Guillermo Gutierrez
We thank Dr Chapman for his comments on new approachesto control hemorrhage. We agree that conservation of bloodand blood products is not just an economic concern, but it isnecessary to protect a limited resource and to preventuntoward effects of such products. Our sections onhypertonic saline and the use of blood substitutes weremeant to address this issue directly. We limited ourdiscussion to a general discussion of hemorrhagic shock anddid not specifically address surgical approaches to thecontrol of bleeding. ‘Damage control’ and packing is a validconcept in the treatment of severely injured patients withhemorrhage [4]. This approach was frequently used inbattlefields, and has become more popular in civilian injury asa method for preventing death from coagulopathy andhypothermia in the operating room. The use of radiologicalembolization as a technique to control ongoing hemorrhagefrom solid organs such as the spleen and the liver has alsosupplemented its use in pelvic hemorrhage. This technique is
not necessarily an ideal therapy for patients who are in shock.Operative intervention is still necessary in unstable patients.
We agree that pharmacological manipulation may be anadjunct to good surgical practice. There are anecdotalreports on the use of activated recombinant factor VII tocontrol bleeding in trauma patients, as well as in numerousother patient populations who do not have hemophilia. Theunencumbered use of this extremely expensive treatment hasled to the loss of millions of dollars in uncompensated careand occasional significant complications. The present statusof this potentially important addition to the armamentarium isunder investigation. Prospective studies need to beperformed to establish efficacy and criteria for use before weembark on this new approach.
Competing interestsThe authors declare that they have no competing interests.
References1. Gutierrez G, Reines HD, Wulf-Gutierrez M: Clinical review: Hem-
orrhagic shock. Crit Care 2004, 8:373-381.2. O’Connell NM, Perry DJ, Hodgson AJ, O’Shaughnessy DF, Laffan
MA, Smith OP: Recombinant FVIIa in the management ofuncontrolled hemorrhage [see comment]. Transfusion 2003,43:1711-1716.
3. Dutton RP, Hess JR, Scalea TM: Recombinant factor VIIa forcontrol of hemorrhage: early experience in critically ill traumapatients. J Clin Anesth 2003, 15:184-188.
4. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd,Fruchterman TM, Kauder DR, Latenser BA, Angood PA: ‘Damagecontrol’: an approach for improved survival in exsanguinatingpenetrating abdominal injury. J Trauma 1993, 35:375-382.
