Shoemaker and colleagues (1973, 1976, 1981) examined the effects of fluid resuscitation on tissue oxygenation and suggested that albumin improved hemodynamic and oxygen transport variables more than lactated Ringer's solution, attributing these results to the greater increases in plasma volume expansion and cardiac output with albumin. Similarly, Hauser and colleagues (1980) showed that infusion of 1 liter of lactated Ringer's solution in critically ill surgical patients with shock expanded the plasma volume 194 ± 18 milliliters (ml) whereas 25 grams of 25 percent albumin (100 ml) increased the plasma volume 465 ± 47 ml. Although hemodilution-related falls in the intravascular protein concentration have continued to raise concerns about crystalloid infusion in shock, the adverse effects of albumin administration on extravascular flux of protein and cardiopulmonary function contributed to the continued use of aggressive crystalloid resuscitation (Carey, 1971; Carey et al., 1970; Cloutier et al., 1969; Cochrane Injuries Group Albumin Reviewers, 1998; Lowe et al., 1979; Lowery et al., 1971; Lucas et al., 1980; Metildi et al., 1984; Moss et al., 1969; Poole et al., 1982; Virgilio et al., 1979).

Although the controversy regarding crystalloid versus colloid resuscitation of the shock patient with hemorrhage continues, most investigators agree that acute hemorrhage-induced changes in plasma volume require replacement with crystalloid solutions at volumes at least three times the volume of the shed blood. A major concern with regard to resuscitation of hemorrhage in a military setting is the considerable weight and volume of crystalloid solutions that must be transported in the field. The large bulk of the lactated Ringer's solution that must be transported compromises the resuscitation phase in forward areas of deployment. In addition, patients with hemorrhagic shock in a combat area are frequently dehydrated, presenting an additional problem for successful resuscitation.

Complications of Resuscitation in General

Although fluid resuscitation is necessary to assist a patient to recover from a loss of blood, there are complications that occur in the administration of the fluid. Fluid resuscitation can have an adverse effect on coagulation, and cause oxygen toxicity or reperfusion-mediated injury. Additionally, there are further complications associated with late resuscitation.

Effects of Fluid Resuscitation on Coagulation

Prolonged bleeding time has been described in patients with severe anemia (Hellem et al., 1961). A decrease in hematocrit as a consequence of large-volume crystalloid resuscitation produces anemia, thrombocytopenia, reduced plasma, and oncotic, clotting, and opsonic proteins. In addition to altered oxygen and CO2 transport, hemodilution and a fall in the circulating red blood cell volume reportedly alter several aspects of coagulation, including bleeding time and platelet adhesiveness and have detrimental effects related to excess, unscav-

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