Logistics of parenteral fluids in battlefield resuscitation

Military Medicine, Sep 1999 by Lyons, William S

The paper discusses the substantial reduction in weight and volume of the fluids of resuscitation that is possible and desirable on the basis of sound physiology and the vast experience of the U.S. Army in four major wars in this century. We note the major shift in emphasis from massive colloid and whole blood in World War II and Korea to massive crystalloid and packed cells in Vietnam and the serious complications with which this was associated. These complications were edematous in nature and best known as the Da Nang lung, or adult respiratory distress syndrome, multiorgan dysfunction syndrome, and systemic inflammatory response syndrome. The advantage of colloid in reducing the weight and volume of resuscitation fluids in forward areas by 60% to 90%, as well as in avoiding the edematous complications of crystalloid-, are emphasized.

Introduction

It is not the intention of this essay to discuss the tonnage or cases of Ringer's lactate needed, or how to move it, with an army on the march. But it is a significant logistical item that can be substantially lightened. For the past 10 years, Fort Detrick has been working with hypertonic saline for resuscitation. At least one of the objectives of this research is a reduction in the weight and volume of fluid required. But hypertonic saline, like large-volume Ringer's lactate, is not physiological and will lead to its own serious complications. Francis Moore, when asked about hypertonic saline, said, bI can't imagine any good coming from something forced parenterally that is toxic when taken by mouth."

Entirely separately, one of us (F.J.P.), at the Walter Reed Army Institute of Research, has been concerned with the logistical problem posed by the large volume of fluids required in the resuscitation process. As a physiologist, he is aware not only of the clinical advantages of colloid, but also of its favorable logistical potential.

This paper will discuss the substantial reduction in weight and volume of resuscitation fluids that is feasible on the basis of sound physiology. It will also provide historical appreciation of the U.S. Army's vast experience with resuscitation in four major wars in this century.

In the war in Southeast Asia a major complication of resuscitation was the adult respiratory distress syndrome (ARDS), or, as it was called at the time, Da Nang lung. It was then, and still is, considered a mystery,1 even now some 30 years after its original description by Ashbaugh and Petty-a mystery in spite of more than 17,000 titles on the subject accessible by computer. But ARDS is not a mystery, but a simple, physical fluid overload phenomenon, the result of the practice of large-volume crystalloid resuscitation.2

One needs only to study the chronicles of the Surgeons General on battlefield casuality management in World War I (WWI), World War II (WWII), Korea, and Vietnam to have driven home, once again, the truth of Santayana's famous expression that "those who will not study history are condemned to repeat it."

At a consensus conference shortly after WWI chaired by George Crile, Sr., and others, the lessons learned in resuscitation were codified.3 Colloid and whole blood were recommended for the restoration of circulating volume. Walter Cannon was very strong for gum acacia ("gum saline"), the early polysaccharide equivalent of present-day dextran and starch.3 The delayed retrieval and exposure suffered by wounded soldiers in WWI presented many in the hemoconcentration thought characteristic of shock. For this phenomenon, crystalloid was thought appropriate, and still would be. It is of interest, however, that hemoconcentration was infrequently seen in the wars after WWI and is no longer considered a hallmark of shock. Rather, spontaneous hemodilution is more characteristic.

It should not be concluded from the consensus conference cited above that resuscitation was as organized or widely practiced in WWI as it has been in subsequent conflicts. Good results were achieved in WWII with colloid and whole blood. The colloid was pooled plasma. It is difficult to believe that WWII was entered with the intention to manage shock with plasma alone. This decision was based on experimental work between WWI and WWII in which it was clearly demonstrated that a reduction in the hematocrit was much better tolerated than a loss of circulating volume. It is common experience now that a 50% hemorrhage is likely to be fatal, whereas even an acute 50% reduction in hematocrit is reasonably well tolerated. So it was thought that plasma alone would suffice. No one seemed to anticipate that with restoration of volume and pressure, the hemorrhage would likely resume. Edward Churchill was appalled. In the African campaign in early 1943, only one casualty in seven received a transfusion; by the end of 1943, one in two received whole blood.

The lessons learned in WWII were not lost sight of in Korea. The liberal use of colloid and whole blood was continued. As a practical matter, the surgeons there simply refused to accept the concept of refractory or irreversible shock. Dextran, gelatin, and albumin, followed by whole blood, were poured in until it ran out everywhere or until the pressure increased. Overtransfusion problems were not identified; certainly respiratory failure was not.4