elimination of D-lactate,


    reduction of total L-lactate load,


    addition of ketones as an energy source, and


    addition of free-radical scavengers and antioxidants (vitamins E and C, glutathione, or iron chelators). (Recommendation 3.1)

    At present, there is insufficient evidence that proposed fluids, such as parenteral saline containing normochloremic carbonate/carbon dioxide: (1) restore blood volume effectively; (2) produce the desired hemodynamic, hematologic, cellular, and immunologic-related advantages; or (3) do not cause adverse events. The ideal solution for fluid resuscitation—one that addresses all of the physiologic and cellular aspects of hemorrhagic shock and that is easy to carry and use in the battlefield—is not apparent at this time. To hasten the development of such a fluid, several changes in the conduct, focus, and direction of resuscitation fluid research will have to take place.

    Proper clinical evaluation of resuscitation fluids and protocols is hampered by the inevitably uncontrolled conditions that accompany clinical trauma and hemorrhage. These include variations in the site and extent of injuries, the duration of hypotension and hypoperfusion, the extent of hypothermia, and the interval before access to definitive care. Much laboratory research has been done with animal models that lack either reproducibility or clear relevance to the clinical scenario, or both. Some fluid resuscitation research has been limited by protocols that did not adequately distinguish or address (1) the differences between pure hemorrhagic shock and traumatic shock associated with tissue injury, (2) the need to standardize the animal models with regard to anesthesia and general care, and (3) the need to observe the subjects for longer-term survival. Clinical research specifically has been hampered by the lack of an organized national approach to trauma research that takes advantage of the considerable clinical material and research expertise among the regional trauma centers. Furthermore, approaches to both current treatment and future research are hampered by inadequate methods for classification of the severity of clinical trauma; such classifications are essential to evaluations of the efficacies of new treatment protocols that involve modifications in fluid formulations or novel therapies. Current trauma indexing systems are inadequate for use in future trauma research.

    Recommendation: A national study group should be convened to develop and implement clinical research, including multicenter clinical trials on selected topics at existing regional trauma centers. Federal agencies, including the U.S. Department of Defense, the U.S. Department of Veterans Affairs, and the National Institutes of Health, and national professional organizations, should collaborate with each other and with the private sector in this activity. (Recommendation 6.2)

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