Eur Surg Res 1991;23:123-129

© 199! S. Karger AG, Basel 0014-312X/91/O232-0123S2.75/0

Treatment of Hemorrhagic Shock with Intraosseous or Intravenous Infusion of Hypertonic Saline Dextran Solution A. Chavez-Negretea , S. M ajluf Cruz*, A. Frati Munari*. A. Perchesb , R. Argueroc “Department of Internal Medicine, bDepartment of Gastroenterology, d ep a rtm en t of Heart Surgery, La Raza Medical Center, IMSS, Mexico City, Mexico

Key Words. Hemorrhage • Hypertonic saline • Hypotension • Hypovolemia • Shock • Intraosseous infusion • Hyperoncotic solution

Gastrointestinal hemorrhage is one of the commonest causes of emergency room ad­ mission in the world [1], Mortality due to this cause ranges from 9 to 29% in North America [2] and it is up to 65% if the bleed­ ing is due to esophageal varices [3], In these cases, quick large intravenous fluid infusions

are required and the infusion of equally ef­ fective rapidly infused low-volume solution should be advantageous. Hypertonic hyper­ oncotic solution (7.5% NaCl/dextran 70) has been found effective in resuscitating animals from hemorrhagic shock, even in volumes as low as 4 ml/kg [4, 5]. Holcroft et al. [6, 7]

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Abstract. The efficacy of intravenous or intraosseous infusion of 250 ml of 7.5% NaCl and 6% dextran 60(H/H) was compared with intravenous Ringer’s lactate (RL) for the initial treatment of patients with hemorrhagic shock due to upper gastrointestinal bleeding. 49 patients were randomly assigned to receive either H/H (n = 26) or RL (n = 23). In the first 16 patients with H/H and in all RL patients, solutions were infused by the intravenous route, while the intraosseous route through sternal puncture was chosen for the last 10 H/H sub­ jects. H/H patients were analyzed together since no differences were noticed between the routes of infusion. The H/H group also received 2.3 ± 0.7 liters of intravenous cristalloid solutions in the first hour and 4.4 ± 0.1 liters in the 24-hour period, while RL received 3.3 ± 0.7 and 7.3 ± 2.4 liters, respectively. Blood pressure (BP) increased during the first 15 min in the H/H group (from 61 ± 17/30 ± 12 to 85 ± 30/48 ± 14 mm Hg) and thereafter, while remaining unchanged in the RL group (from 75 ± 18/40 ± 12 to 75 ± 17/40 ± 14 mm Hg; p < 0.05). The differences between groups were significant throughout 24 h. Urine output and improvement of the Glasgow Coma Score were also higher in H/H patients than in the control group (p < 0.05). There were 5 deaths in RL group and 1 in the H/H group. Sternal of peripheral vein infusion of 250 ml of 7.5% NaCl/6% dextran 60 is an effective initial treat­ ment of hemorrhagic shock.


Châvez-Negrete/Majluf Cruz/Frati Munari/Perches/Argüero

Table 1. Clinical data on entry H/H (7.5% NaCl/6% dextran 60) — i.v (n = 16)

i.o (n = 10)

Age, years Mean Range

42 22-76



42 52-58

Gender (M/F)





Blood pressure Systolic, mm Hg Diastolic, mm Hg

64 ±21 32± 14

56 ±18 17± 10

63 ±20 33 ±17

75 ± 18 40 ±12

Heart rate

113 ± 15

119 ± 16

109 ±13

112 ± 19

Hb. g/dl

8.6 ±2

8.2 ± 2


8.6 ± 3

Hct, %

29 ± 6

29 ±7

30 ±5

27 ± 8



9± 1

!0 ± 1

9 7 -

3 4 3

9 14 -

Glasgow Coma Score Etiology of bleeding Peptic ulcer Esophageal varices Others

12 11 3

reported improved blood pressure and sur­ vival with hypertonic saline/dextran solu­ tion in severely injured patients. Also in pa­ tients with hemorrhagic shock, wide intrave­ nous catheters are needed. However, the in­ sertion of wide catheters is not always easy in patients with hypovolemia and collapsed pe­ ripheral veins [8]. This problem can be solved using alternative routes to infuse fluids. Intraosseous infusion has been pro­ posed as an alternative route to reach the blood stream since it provides a rapid vascu­ lar access [9], This is a prospective, controlled study which evaluates the administration of hypertonic/hyperoncotic (H/H) solutions through the intravenous or intraosseous route in the management of hemorrhagic shock due to gastrointestinal bleeding.

Patients and Methods Adult patients with acute gastrointestinal hemor­ rhage and arterial hypotension were selected from the Emergency Room of Gastroenterology and Internal Medicine Departments. Inclusion criteria were: (a) systolic blood pressure equal or lower than 90 mm Hg for less than 1 h; (b) normal electrocardiogram, and (c) written consent by the patients or if it was not possible by a first-degree relative. Patients were not included when pregnancy, renal, cardiac or neurolog­ ical diseases were present. 49 consecutive patients were assigned by random numbers to be treated either with 250ml of 7.5% NaCl/6% dextran 60 solution (H/H) (Schiwa GmbH, Glandorf, FRG) (group 1) or conventional lactated Ringer’s (LR) (group 2). H/H has an osmolality of 2,400 mosm/1 while LR has 276 mosm/1. All solutions were administered as soon as possible (on admission or few minutes after the begin­ ning of bleeding if patients were already hospitalized) by peripheral vein in the first 16 patients of group 1 and in all patients of group 2, while the intraosseous route was used in the last 10 patients with H/H. When

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total (n = 26)

LR i.v. (lactated Ringer's) (n - 23)

Hypertonie Saline Dextran in Hemorrhagic Shock

the intraosseous route was chosen, a 1.5-cm deep ster­ nal puncture was performed with a 14-gauge needle which was inserted between the second and third intercostal space [9]. At the end of H/H or Ringer lactate infusion, sup­ plemental isotonic saline fluid was administered through the peripheral vein in both groups as neces­ sary in order to achieve a systolic blood pressure higher than 100 mm Hg. In addition, dextran 40 was administered to the control group if necessary accord­ ing to medical judgement. Packed red cells were transfused if bleeding or hypotension was present after the first 15 min of treatment, or if they reap­ peared within the next 24 h. Also, standard etiological treatment was carried out in every case (e.g. patients with esophageal varices required a Sengstaken-Blakemore tube, those with peptic ulcer received antacid and cimetidine). Blood pressure, heart rate, Glasgow Coma Score at 15, 30 and 60 min and 4, 8 and 24 h were recorded. Blood count, BUN, serum creatinine, and serum electrolytes and arterial gases were deter­ mined at arrival and at 24 h. All data in figures and tables are presented as mean ± SD. Statistical methods were analysis of vari­ ance and paired Student’s t test, p < 0.05 was consid­ ered significant. The study was approved by the Hos­ pital Ethical-Investigation Committee.


Fig. 1. Blood pressure after H/H infusion of up to 24 h by peripheral vein (n = 16; •), intraosseous route (n « 10; o) and LR group (n = 23; o). A significant difference was noticed (p < 0.05) between the H/H group and control group at 15 min after infusion. No differences were found between intraosseous or intra­ venous infusion in the H/H group. For clarity pur­ poses, only mean values are shown.

Fourty-nine patients were studied: 26 re­ ceived H/H through the peripheral vein (16 patients) or by the intraosseous route (10 patients) while 23 individuals were in the control group with LR. There were no differ­ ences in initial demographic or clinical data, or blood pressure, pulse rate or therapeutic response between patients who received H/H solution by the peripheral vein or by the intraosseous route. Thus they were further analysed as a whole group. On entry, age, gender, blood pressure, heart rate, Glasgow Coma Score, hematocrit as well as the etiol­ ogy and site of hemorrhage were similar in group 1 and 2 (table 1). A nearly identical

significant increase in BP was noted 15 min after sternal or intravenous infusion of H/H (63 ± 21/33 ± 17/91 ± 20/50 ± 20 and 61 ± 17/30 ± 12 to 85 ± 30/48 ± 14 mm Hg, respectively). Blood pressure rose from 15 min on and thereafter with the infusion of H/H with sta­ tistical significance (p < 0.05) as compared with the control group (fig. 1). Hypotension persisted for at least 1 h in several patients of the control group despite rapid infusion of intravenous fluids. Patients of group 1 re­ ceived 2,360 ± 723 ml of cristalloid solu­ tions in the first hour, while subjects of group 2 received 3,312 ± 750 ml in the same

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Chavcz-Negrete/Vlajluf Cruz/Frati Munari/Perches/Argiiero

Fig. 2. Heart rate values after H/H (intraosseous and peripheral vein; n - 26; •) vs. LR group (n = 23; o). Bars indicate the SD. Differences between groups were not significant (p > 0.05).

period. Heart rate decreased throughout the 24 h in both groups, without difference be­ tween groups (fig. 2). 24-Hour urine output was higher in group 1 than in group 2 although group 1 re­ ceived only 4,400 ± 188 ml of supplemental fluids in 24 h while in group 2 7,300 ± 2,400 ml were infused in the same period (fig. 3). Serum electrolytes at the time of en­ try and after 24 h were within normal limits in both groups (data not shown). The amount of packed red cells transfused was also higher in controls (950 ± 500 ml) than in the H/H group (480 ± 200 ml p < 0.05). Most patients of group 2 received two or more units of packed red cells while only 7 subjects of group 1 received two or three units (table 2). In spite of transfusions, only

Fig. 3. 24-Hour urine output af­ ter H/H (intraosseous and periph­ eral vein) infusion vs. LR group (p < 0.05) and supplemental fluids in both groups (p = NS).

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Hypertonie Saline Dextran in Hemorrhagic Shock

a mild nonsignificant improvement of ane­ mia was noticed at 24 h in both groups which reflects the magnitude of the hemor­ rhage. On entry, pa02 was lower in the H/H group than in the control group; however, it rose close to normal limits in the following 24 h (table 3). A significant improvement of neurological status was also noticed in H/H patients reaching statistical significance at 24 h (p < 0.05) (fig. 4). The improvement was best noticed in those patients with an initial Glasgow Coma Score lower than 10 (table 4). Within the 24 h of the study, 5 patients died in the control group while only 1 died in the H/H group.

Table 2. Packed red cell requirement Solutions

7.5% NaCl/6% dextran 60 Lactatcd Ringer’s

Units (300 ml) 0



4 0

15 1

6 13

3 >4 1 3

0 6

Fig. 4. Glasgow Coma Score at entry and after 24 h in patients receiving H/H (7.5% NaCl/6% dextran 60) or LR (lactatcd Ringer’s). Though improve­ ment was seen in both groups, it was significant only in the H/H group (p < 0.05, Mann-Whitney U test). The differences between the number of patients who improved in H/H vs. LR were also significant (p < 0.02, Fisher’s test).

Table 3. Arterial blood gases Entry


24 h



9 6

7.37 + 0.3 7.36±0.4

7.4 ±0.8 7.34±0.7

7.42 ±0.6 7.36±0.2

pCOi, mm Hg


9 6

17.8 ±1.04 34.1+2

20.8 ±4 34.6 ± 1

23.27 ±2.2* 35.2 ±1.4

pO;, mm Hg


9 6

44.5 ± 15 61.5 + 5

HCOt, mEq/1


9 6

11.9 ± 2 18.6 ± 7

Results expressed as X ± SD. * p < 0.05: entry vs. 24 h later. No mechanical ventilation was used (FI0., 21 %).

65± 16 69 ± 18 14.4 ±2 22 ±2

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Table 4. Glasgow Coma Score Solution


Entry Score after score 24 h X ± SD

7.5% NaCl/6% dextran 60

10 6

< 10 + 5.5+ 1.4* > 10 + 2.16 ± 0.4

Lactatcd Ringer’s

0 ± 0 .5 b 10 < 10 6 > 10 +1.9 ± 1.5

* p < 0.05 a versus b.

Discussion Velasco et al. [10] reported in 1980 that 4 ml/kg of 7.5% NaCl solution was effective in resuscitating animals from hypovolemic shock. Later, Smith et al. [11] found that the combination of 7.5% sodium chloride with 6% dextran 70 was more effective than hy­ pertonic saline alone; this solution also re­ stored acid-base balance, urine output and tissue oxygen consumption in hypovolemic animals [12], Holcroft et al. [6, 7] showed that a similar hypertonic/hyperoncotic solu­ tion (7.5% saline/4.2% dextran 70) en­ hanced blood pressure in severely injured patients. In this study, H/H solution was effective in patients with severe hemorrhage restoring blood pressure within few minutes, and the beneficial effect lasted for the next 24 h. Re­ markably, in the control group, blood pres­ sure did not immediately rise in spite of large volume replacement. The immediate hemodynamic effects of H/H solution can be ascribed to its hyperosmolality, which causes plasma volume expansion [13], enhance­ ment of myocardial contractility [14] and higher blood pressure, leading to a rise of

organ blood flow [12, 15]. In this study, blood pressure increased as well as urine out­ put. The last may be the result from both higher renal blood flow [16] and osmotic diuresis. The improvement in arterial pCL after H/H may be a consequence of better hemodynamic conditions. Neurological improvement measured by the Glasgow Coma Score that was noticed mostly in patients treated with H/H solution was consistent with the overall clinical sta­ tus. Although we did not measure intracra­ nial pressure, it is noteworthy that in experi­ mental animals, resuscitation from hemor­ rhagic shock with isotonic fluids resulted in enhancement of intracranial pressure while hypertonic fluids maintain low intracranial pressure [17, 18], Intraosseous injection of H/H has been proposed as a rapid means of gaining vascu­ lar access when peripheral cannulation is dif­ ficult [9], Intraosseous infusion is easy to per­ form and does not require special training. In the present study, 10 patients were injected into the sternum with 250 ml of H/H without complications. Volume expansion with this method was as rapid and effective as periph­ eral vein infusion. This method may be use­ ful in emergencies if peripheral veins are not readily accessible. In this study, no complica­ tions ascribed to H/H solution or to intraos­ seous sternal infusion were seen. It is known that conventional therapy and emergency surgery have failed to reduce the overall mortality of bleeding from esophageal varices [19], Likewise, in this study, mortal­ ity was due to hemorrhage from esophageal varices in all the cases. In the H/H group there was only 1 death, while there were 5 deaths in the control group, although both groups were similar in initial clinical status, hematocrit and cause of bleeding. Further­

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Chávez-Negrete/Majluf Cruz/Frati Munari/Perches/Argüero

Hypertonie Saline Dextran in Hemorrhagic Shock

References 1 Gostout CJ: Acute gastrointestinal bleeding - A common problem revisisted. Mayo Clin Proc 1988;63:596-604. 2 Halmagyi AF: A critical review of 425 patients with upper gastrointestinal hemorrhage. Surg Gy­ necol Obstet 1970;130:419-430. 3 Westaby D, Macongall B, Williams R: Improved survival following injection sclerotherapy for esophageal varices. Final analysis of a controlled trial. Hepatology 1985;5:827-830. 4 Kramer GC, Perron PR. Lindsey DC. et al: Smallvolume resuscitation with hypertonic saline dextran solution. Surgery 1986;100:239-246. 5 Maningas PA, De Guzman LR, Tillman FJ, et al: Small volume infusion of 7.5% NaCI in dextran 70 for the treatment of severe hemorrhagic shock in swine. Ann Emcrg Med 1986; 15:1131-1137. 6 Holcroft JW, Vassar MJ, Tunncr JE, et al: 3% NaCI and 7.5% NaCl/dextran 70 in the resuscita­ tion o f severely injured patients. Ann Surg 1987; 206:279-286. 7 Holcroft JW, Vassar MJ, Perry CA, et al: Perspec­ tives on clinical trials for hypertonic saline/dextran solutions for the treatment of traumatic shock. Brazilian J Med Biol Res I989;22:291293. 8 Smith Jp, Bosai BI, Hill AS, Frey CF: Prehospital stabilization of critically injured patients: A failed concept. J Trauma 1985;25:65-70. 9 Saavedra J, Patterson HA, Kramer GC: Intraos­











seous injection of hypertonic saline dextran. Ana­ tomic considerations in man and sheep. Circ Shock 1988;24:283. Velasco LT, Pontieri V, Rocha-e Silva M Jr. Lopez OU: Hyperosmotic NaCI and severe hemorrhagic shock. Am J Physiol 1980;239:H664-H673. Smith GJ, Kramer JC. Perron P. et al: A compar­ ison of several hypertonic solutions for resuscita­ tion of bled sheep. J Surg Res 1985;39:517-528. Baue AE, Tragus ET, Parkins WM: A comparison of isotonic and hypertonic solution blood on blood flow and oxygen consumption in the initial treatment of hemorrhage shock. J Trauma 1967;7: 743-756. Nakayama S, Sibley L, Gunther R: Small volume resuscitation with hypertonic saline (2,400 mosm/ liter) during hemorrhagic shock. Circ Shock 1989; 13:149-159. Koch-Weser J: Influence of osmolarity of perfu­ sate on contractility of mammalian myocardium. Am J Physiol 1963;204:957-962. Kreimeier U, Brueckner U B. Messmer K: Improve­ ment of nutritional blood flow using hypertonic solution for primary treatment of hemorrhagic hy­ potension. Eur Surg Res 1988;20:277-279. Loveday E: Resuscitation of conscious pigs fol­ lowing hemorrhage: Renal function before and after 7.5% NaCl/6% dextran solution administra­ tion. Circ Shock 1988:24:248. Prough DS, Johnson JC, Poole GV, et al: Effects of intracranial pressure of resuscitation from hem­ orrhagic shock with hypertonic saline versus lactated Ringer’s solution. Crit Care Med 1987;43: 407-411. Poole GV Jr, Johnson JC, Prough DS, et al: Cere­ bral hemodynamics after hemorrhagic shock: Ef­ fects of the type of resuscitation fluid. Crit Care Med 1986;14:629-633. Crook JN, Gray LW Jr, Nance FC, Cohn I Jr: Upper gastrointestinal bleeding. Ann Surg 1972; 175:771-782. Received: June 25, 1990 Accepted: January 2, 1991 Adolfo Chávez-Negrete, MD Hospital de Especialidades Centro Médico La Raza IMSS Depto. Medicina Interna Seris y Zaachila, Col. La Raza CP 2990 Azcapotzalco México DF (Mexico)

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more, a greater amount of blood was trans­ fused in patients of the control group. This findings might reflect the beneficial influence of the rapid improvement of blood pressure and tissue perfusion due to H/H solutions. Nevertheless, the outcome could also be ascribed to a different severity of bleeding during follow-up. 250 ml of H/H solution, either by the peripheral vein or the intraosseous route, showed to be useful in reversing short-time hypotension due to severe upper gastrointes­ tinal bleeding.


Treatment of hemorrhagic shock with intraosseous or intravenous infusion of hypertonic saline dextran solution.

The efficacy of intravenous or intraosseous infusion of 250 ml of 7.5% NaCl and 6% dextran 60 (H/H) was compared with intravenous Ringer's lactate (RL...
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