Fluid management in hemorrhagic shock

Fluid management in hemorrhagic shock is a controversial topic, and there are evolving clinical guidelines and evidence-based practice. This review aims to highlight the physiological aspects in the light of current evidence on which volume replacement solution to use.

Current evidence and international guidelines are shifting from a liberal to a restrictive volume resuscitation strategy, emphasizing the potential risks associated with aggressive fluid therapy. The 'lethal triad of trauma' (hypoperfusion, acidosis, and coagulopathy) plays a crucial role in the pathophysiology of hemorrhagic shock. While crystalloids are less effective at restoring intravascular volume, colloids (especially hydroxyethyl starch) have raised concerns about potential adverse effects on renal function and coagulation. Albumin remains controversial, as studies have shown no clear benefit and an increased mortality in traumatic brain injury patients. Fresh frozen plasma may be useful in massive transfusion situations but is not recommended for volume resuscitation.

The management of volume resuscitation evolves, with a trend toward more restrictive strategies. Crystalloids, although less effective for severe volume depletion, remain a cornerstone of initial resuscitation. Among the colloids, gelatin-based solutions and albumin can be used when crystalloids are inadequate, while hydroxyethyl starch is no longer recommended.