Limiting initial resuscitation of uncontrolled hemorrhage reduces internal bleeding and subsequent volume requirements

We tested the hypothesis that full or 'standard resuscitation' (SR) with lactated Ringer's solution (LRS) results in increased bleeding in uncontrolled hemorrhagic shock, compared with a 'limited prehospital resuscitation' (LPR) regimen and a control group of 'no resuscitation' (NR). Cardiac output was used as physiological endpoint for resuscitation. Twenty swine had 25 mL/kg of blood withdrawn during a 30-minute controlled hemorrhage, followed by a 20-minute uncontrolled hemorrhage (5 mm aortotomy). A 20-minute 'prehospital' resuscitation regimen was conducted in three groups: the SR group (n = 6), LRS infused as needed to restore cardiac index (CI) to 100% baseline; the LPR group (n = 8), with resuscitation using LRS to 60% of baseline CI, with volume limited to 10 mL/kg; and the NR group (n = 6). After aortotomy repair, intraoperative resuscitation was continued for 120 minutes using LRS to achieve and maintain 80% of baseline mean arterial pressure. Blood pressure and cardiac index were greatly reduced, to 34% and 39% of baseline, respectively, by hemorrhage. During prehospital resuscitation, the SR group required 48.8 ± 6.5 mL/kg of LRS, whereas the LPR group received 9.4 ± 0.6 mL/kg (p < 0.05). Mean arterial pressure increased in all three groups during prehospital resuscitation (p < 0.05). Pulse pressures increased in the SR and LPR groups only (p < 0.05). The increment in oxygen delivery was significantly greater in the SR group, compared with the LPR group (p < 0.05), which in turn was significantly greater than the NR group (p < 0.05). Peritoneal blood volume was significantly higher in the SR group (20.6 ± 5.6 mL/kg), versus the LPR (7.3 ± 1.3 mL/kg; p < 0.05) and NR groups (3.0 ± 0.9 mL/kg; p < 0.05). Crystalloid and whole blood requirements during the intraoperative resuscitation phase were significantly higher in the SR group (193 ± 16.0 and 9.0 ± 2.5 mL/kg), than in LPR (111.8 ± 15.6 and 4.5 ± 1.8 mL/kg; p < 0.05) and NR groups (128.5 ± 32.3 and 3.9 ± 2.3 mL/kg; p < 0.05). In the presence of uncontrolled hemorrhagic shock, LPR and NR can significantly reduce internal hemorrhage and subsequent intraoperative crystalloid and blood requirements.