Hazards of subclavian vein catheterization

188

Injury: the British Journal of Accident Surgery Vol. ~/NO. 2

SHOCK Acidosis

from

blood transfusion

Large blood transfusions might be expected to cause acidosis. Acid-base changes were therefore studied in a number of combat casualties. Patients who responded well to transfusion handled the acid load well. Worsening acidaemia was associated with uncontrolled haemorrhage and was considered more likely to be due to shock than to transfusion. COLLINS, J. A., SIMMONS, R. L., JAMES, P. M., BREDENBERG, C. E., ANDERSON,R. W., and HEISTERKAMP, C. A. (1971), ‘Acid base status ol” seriously wounded combat casualties ‘, Ann. Sur~~., 173, 6. Gelatin

Electrolyte solutions resuscitation

for shock

The effect of infusion of a 3 per cent gelatin solution in quantities up to 50 per cent of blood-volume in dogs suffering from haemorrhagic shock was studied. No harmful effect on acid-base equilibrium or the ionic or albumen concentration in plasma was found and normal coagulation was not disturbed. It is concluded that this infusion can be used as a substitute for blood for volumes up to 500-1000 ml. The authors do not claim to have any clinical experience with this substance but give a reference to its ‘ widespread ’ use in Europe. HABIF, D. V., DEBBAS,E., MIGUE, J., and NAHAS, G. G. (1971), ‘ A balanced fluid gelatin for the treatment of haemorrhage ‘, Ann. Surg., 173, 85. Bleeding

diathesis

after

massive

transfusion

This has been noted in patients subjected to transfusions of over 20 to 25 units. Investigations in 21 combat casualties revealed 12 instances of thrombocytopenia, probably dilutional in origin. Fresh bIood (but not fresh frozen plasma) corrected the disorder. MILLER, R. N., ROBBINS,T. O., TONG, M. J., and BARTON,S. L. (1971), ‘ Coagulation defects associated with massive blood transfusions ‘, Ann. SW,,., 174, 794. Hazards

of subclavian

vein catheterization

Subclavian vein catheterization

can be a very useful procedure in shocked patients as well as in many other contexts. It has, however, a number of hazards and complications. These two articles suggest safeguards and treatment>. BERNARD, R. W., and STAHL, W. M. (1971), ‘ Subclavian vein catheretizations : a prospective study. I, Non-infectious complications; II, Infectious complications ‘, Ann. Surg., 173, 184, 191. Studies

cardiac output, systemic blood-pressure and central blood-volume, increase in pulmonary artery pressure and vascular resistance, and an increase in pulmonary oxygen exchange and pulmonary extravascular waler volume. There is reason to believe that early restoration of the abnormal pulmonary blood-flow might prevent the later development of pulmonary insufficiency. WYCHE, M. Q., MARSHALL,B. E., MEHALL,S. L., and SCHUETZE, M. M. (1971), ‘Lung function, pulmonary extravascular water volume and haemodynamics in early haemorrhagic shock in anaesthetised dogs ‘, Ann. &r&r., 174, 296.

in shock

Haemorrhagic shock was established in dogs by the withdrawal and subsequent re-infusion of blood. Studies of the effects showed a progressive decrease in

in addition

to blood

in

While waiting for blood to be fully cross-matched in cases of haemorrhagic shock, there is much discussion nowadays on the use of substantial quantities of electrolyte solution. After reviewing the arguments, this paper goes on to investigate the rival claims of normal saline and of Ringer lactate solution. The investigation was a prospective study carried out on severely wounded servicemen. The conclusion is reached that blood combined with electrolyte solution is effective in resuscitation. The desirability of the large volumes involved (quantities of electrolyte in the order of 5 litres and of blood of the order of 10 litres) is discussed. No oedema occurred except in cases of fat embolism. Lung complications are not mentioned. Only minor differences were found in the effects of the saline as compared with the lactate solution. The latter was not found to be harmful and it does not obviate the usefulness of blood lactate determinations. LOWERY,B. D., CLOUTIER,C. T., and CAREY,L. C. in (l97l), ‘ Electrolyte solutions in resuscitation human haemorrhagic shock ‘, SrrvgerJJ G~~nec.Ohsfet., 133, 273. Treatment America

of

severe

multiple

trauma

in

Ten seriously injured battle casualties considered to have renal failure were studied. Most were found to be also in respiratory failure. Before dialysis the patients had variously been given 24 to 29 litres (or units) of blood, also ‘ large volumes ’ of crystalloid fluids. Their fluid excesses were estimated to be from 2: to I1 litres plus unrecorded amounts given during initial resuscitation. The predominant clinical feature was respiratory distress. The author is not sure whether over-hydration was responsible for the respiratory failure but thinks that dialysis is helpful. Three patients survived. ZIMMERMAN,J. E. (1971), ‘ Respiratory failure complicating post-traumatic acute renal failure ‘, Ann. Surg.,

174, 12.