Plasma and Vitamin C for shock resuscitation.

While it is easy to make the steady-state Starling case against colloids for resuscitation from hypovolaemia,  the argument from microvascular flow preservation keeps alive a possible indication for plasma infusions. The endothelial glycocalyx (EG) disintegrates after severe hemorrhagic shock, and there is laboratory evidence that plasma  could preserve or restore capillary integrity. Lyophilised plasma seems to be attracting new attention, (1) and a simple experiment to identify the best solution in which to reconstitute the plasma has been reported.  (2). Sterile Water or Lactated Ringers are associated with smaller blood loss and lower IL-6 response than Normal Saline or Hextend, so water is fine. But then I notice a qualifier; the water and the lactated ringers reconstituted plasma solutions were ‘buffered with ascorbic acid’! Turns out that ascorbic acid pH adjustment of the reconstituted plasma solution confers advantages over HCl or citric acid. (3,4,5) This comes on top of a randomised controlled clinical trial showing that ascorbic acid substantially reduces the volume of fluid needed to resuscitate patients with major burn injury. (6) Though this single-centre trial has still not been confirmed in larger multi centre trials, it is reported that vitamin C has been adopted in many burn centers as an adjunct to resuscitation.  (7) I can only wonder why the Sepsis Mafia are so strongly opposed to the adoption of the Norfolk Protocol as adjunctive therapy in sepsis. Do we have to get multi centre RCCT evidence for ascorbic acid buffering of reconstituted lyophilised plasma vs unbuffered reconstituted LP??

  1. Shock 2016 Nov. 46:468-479
  2. J Trauma Acute Care Surg 2014 Feb. 76:264-1
  3. J Trauma 2011 Jul. 71:20-4
  4. J Trauma 2011 Aug. 71:292-7
  5. J Trauma Acute Care Surg 2015
  6. Arch Surg 2000 Mar. 135:326-31.
  7. J Burn Care Res 2015 Jan-Feb. 36:50-6.

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