In 1872 Pflüger published that the organs in shock need flow rather then pressure. It took however nearly a century to rediscover these facts. In 1973 Shoemaker demonstrated that flow related parameters were higher in surviving patients, who underwent surgery then in nonsurvivers. He showed that survivers had higher cardiac index, higher oxygen delivery and higher VO2 compared to nonsurvivers and these values are regarded as "prognostic indices" for survival hence. Therapy therefore should be targeted towards restoring tissue perfusion with most effective therapeutics as quickly as possible. Volume therapy is closely based on the findings of Ernst von Bergman in 1878 that death by shock of hemorrhage is rather related to the loss of circulating blood volume then loss of erythrocytes.

Consequently clinicians like Sander treated shock with saline infusions. Dextranes were introduced into therapy in 1944 and finally hydroethylstarch was discovered by Thomson and Walton in 1962 in the search for less allergenic volume substitutes. Currently a broad variety of volume therapeutics bases on starch are in clinical use besides gelatine and human albumin. Since there is a worldwide shortage on blood components, the use of artificial colloids has been widely accepted.

We tested the hemodynamic effects of volume replacement by different fluids including human albumin Hes 6%, 10% of different molecular weights, ringers lactate under intraoperative and ICU-conditions. In periods of relative volume deficits at wedge pressures of 11-13 mmHg each fluid was given to correct the volume deficit. Each therapeutic was given until a wedge pressure of 18 mmHg was reached.

Our data suggest that all colloids improve flow related parameters. The 10% Hes solution however intraoperatively and in the intensive care condition improved cardiac output, DO2 and VO2 most favourably.

Key words: Volume substitutes, history, bloodvolume, hydroxyethylstarch, cristalloids, Shoemaker concept, coagulation, "Bremer Schema", "prognostic indices"

Dr. K. Hankeln
Abteilung für Anästhesie und Intensivmedizin
Zentralkrankenhaus Bremen-Nord
Hammersbecker Str. 228
D-28755 Bremen