***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : To compare the effects of a bolus infusion of hypertonic saline hydroxyethyl starch with the effects of normal saline ( placebo ) on intracranial pressure ( ICP ) and cerebral perfusion pressure in patients with spontaneous subarachnoid hemorrhage . Design and Setting : Prospect i ve , r and omized , single-blinded , placebo-controlled study in a university hospital . Patients : A total of 22 mechanically ventilated patients with spontaneous subarachnoid hemorrhage with stable ICP between 10 and 20 mm Hg . Interventions : During the course of 30 mins , 2 mL/kg of either 7.2 % saline in 6 % hydroxyethyl starch 200/0.5 ( HSS ) or of normal saline was infused . The effects were observed for another 180 mins . Measurements and Main Results : Mean change in ICP after intervention ( & Dgr;ICP ) calculated from the average of all observations was −3.3 ( sd 2.6 ) mm Hg in the HSS group vs. −0.3 ( sd 1.3 ) mm Hg in the normal saline group . Mean difference between the groups ( HSS − normal saline ) was −3.0 mm Hg ( 95 % confidence interval , −4.9 to −1.1 ; p = .004 ) . Mean peak change after HSS was −5.6 ( range , −0.8 to −12.2 ) mm Hg after 64 ( range , 40 to 115 ) mins . Mean difference in cerebral perfusion pressure change between the groups ( HSS − normal saline ) was 5.4 mm Hg ( 95 % confidence interval , 2.2 to 8.6 ; p = .002 ) , and mean difference in cardiac index change , measured as the area under the curve for the whole study period , corresponded to 0.2 L·min−1·m−2 ( 95 % confidence interval , 0.03 to 0.4 ; p = .025 ) . Conclusions : In this placebo-controlled study involving spontaneous subarachnoid hemorrhage patients with normal to moderately increased ICP , 2 mL/kg HSS  reduced ICP and increased cerebral perfusion pressure significantly . Maximum effect was reached at twice the infusion time of 30 mins . There were also beneficial hemodynamic effects with increased cardiac index in the HSS group Background Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial . A number of initiatives have aim ed to provide guidance on the management of trauma patients . This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution . Methods The pan-European , multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies . The group used a structured , evidence -based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale . Expert opinion and current clinical practice were also considered , particularly in areas in which r and omised clinical trials have not or can not be performed . Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice ; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated . This guideline represents the fourth edition of a document first published in 2007 and up date d in 2010 and 2013 . Results The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation . Best- practice use of blood products during further resuscitation continues to evolve and should be guided by a goal -directed strategy . The identification and management of patients pre-treated with anticoagulant agents  continues to pose a real challenge , despite accumulating experience and awareness . The present guideline should be viewed as an educational aid to improve and st and ardise the care of the bleeding trauma patients across Europe and beyond . This document may also serve as a basis for local implementation . Furthermore , local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome . Conclusions A multidisciplinary approach and adherence to evidence -based guidance are key to improving patient outcomes . The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome Introduction Fluid administration in critically ill patients may affect acid-base balance . However , the effect of the fluid type used for resuscitation on acid-base balance remains controversial . Methods We studied the effect of fluid resuscitation of normal saline and the colloids gelatine 4 % , hydroxyethyl starch ( HES ) 6 % , and albumin 5 % on acid-base balance in 115 clinical ly hypovolemic critically ill patients during a 90 minute filling pressure-guided fluid challenge by a post-hoc analysis of a prospect i ve r and omized clinical trial . Results About 1700 mL was infused per patient in the saline and 1500 mL in each of the colloid groups ( P<0.001 ) . Overall , fluid loading slightly decreased pH ( P<0.001 ) and there was no intergroup difference . This mildly metabolic acidifying effect was caused by a small increase in chloride concentration and decrease in strong ion difference in the saline- and HES- , and an increase in ( uncorrected ) anion gap in gelatine- and albumin-loaded patients , independent of lactate concentrations . Conclusion In clinical ly hypovolemic , critically ill patients , fluid resuscitation by only 1500–1700 mL of normal saline , gelatine , HES or albumin , result ed in a small decrease in pH , irrespective of the type of fluid used . Therefore , a progressive metabolic acidosis , even with increased anion gap , should not be erroneously attributed to insufficient fluid resuscitation . Trial registration IS RCT N Registry IS RCT Background Clinical trials evaluating the use of hypertonic saline in the treatment of hypovolemia and head trauma suggest no survival superiority over normal saline ; however subgroup analyses suggest there may be a reduction in the inflammatory response and multiorgan failure which may lead to better survival and enhanced neurocognitive function . We describe a feasibility study of r and omizing head injured patients to hypertonic saline and dextran vs. normal saline administration in the out of hospital setting . Methods / Design This feasibility study employs a r and omized , placebo-controlled design evaluating normal saline compared with a single dose of 250 ml of 7.5 % hypertonic saline in 6 % dextran 70 in the management of traumatic brain injuries . The primary feasibility endpoints of the trial were : 1 ) baseline survival rates for the treatment and control group to aid in the design of a definitive multicentre trial , 2 ) r and omization compliance rate , 3 ) ease of protocol implementation in the out-of-hospital setting , and 4 ) adverse event rate of HSD infusion . The secondary objectives include measuring the effect of HSD in modulating the immuno-inflammatory response to severe head injury and its effect on modulating the release of neuro-biomarkers into serum ; evaluating the role of serum neuro-biomarkers in predicting patient outcome and clinical response to HSD intervention ; evaluating effects of HSD on brain atrophy post-injury and neurocognitive and neuropsychological outcomes . Discussion We anticipate three aspects of the trial will present challenges to trial success ; ethical dem and s associated with a waiver of consent trial , challenging follow up and comprehensive accurate timely data collection of patient identifiers and clinical or laboratory values . In addition all the data collection tools had to be derived de novo as none existed in the literature .Trial registration Background Traumatic brain injury ( TBI ) initiates interrelated inflammatory and coagulation cascades characterized by wide-spread cellular activation , induction of leukocyte and endothelial cell adhesion molecules and release of soluble pro/antiinflammatory cytokines and thrombotic mediators . Resuscitative care is focused on optimizing cerebral perfusion and reducing secondary injury processes . Hypertonic saline is an effective osmotherapeutic agent for the treatment of intracranial hypertension and has immunomodulatory properties that may confer neuroprotection . This study examined the impact of hypertonic fluids on inflammatory/coagulation cascades in isolated head injury . Methods Using a prospect i ve , r and omized controlled trial we investigated the impact of prehospital resuscitation of severe TBI ( GCS < 8) patients using 7.5 % hypertonic saline in combination with 6 % dextran-70 ( HSD ) vs 0.9 % normal saline ( NS ) , on selected cellular and soluble inflammatory/coagulation markers . Serial blood sample s were drawn from 65 patients ( 30 HSD , 35 NS ) at the time of hospital admission and at 12 , 24 , and 48-h post-resuscitation . Flow cytometry was used to analyze leukocyte cell-surface adhesion ( CD62L , CD11b ) and degranulation ( CD63 , CD66b ) molecules . Circulating concentrations of soluble (s)L- and sE-selectins ( sL- , sE-selectins ) , vascular and intercellular adhesion molecules ( sVCAM-1 , sICAM-1 ) , pro/antiinflammatory cytokines [ tumor necrosis factor (TNF)-α and interleukin ( IL-10 ) ] , tissue factor ( sTF ) , thrombomodulin ( sTM ) and D-dimers ( D-D ) were assessed by enzyme immunoassay . Twenty-five healthy subjects were studied as a control group . Results TBI provoked marked alterations in a majority of the inflammatory/coagulation markers assessed in all patients . Relative to control , NS patients showed up to a 2-fold higher surface expression of CD62L , CD11b and CD66b on polymorphonuclear neutrophils ( PMNs ) and monocytes that persisted for 48-h . HSD blunted the expression of these cell-surface activation/adhesion molecules at all time-points to levels approaching control values . Admission concentrations of endothelial-derived sVCAM-1 and sE-selectin were generally reduced in HSD patients . Circulating sL-selectin levels were significantly elevated at 12 and 48 , but not 24 h post-resuscitation with  HSD . TNF-α and IL-10 levels were elevated above control throughout the study period in all patients , but were reduced in HSD patients . Plasma sTF and D-D levels were also significantly lower in HSD patients , whereas sTM levels remained at control levels . Conclusions These findings support an important modulatory role of HSD resuscitation in attenuating the upregulation of leukocyte/endothelial cell proinflammatory/prothrombotic mediators , which may help ameliorate secondary brain injury after TBI.Trial registration NCT00878631 To assess the effects of crystalloid and colloid resuscitation on hemodynamic response and on lung water  following thermal injury , 79 patients were assigned r and omly to receive lactated Ringer 's solution or 2.5 % albumin-lactated Ringer 's solution . Crystalloid-treated patients required more fluid for successful resuscitation than did those receiving colloid solutions ( 3.81 vs. 2.98 ml/kg body weight/% body surface burn , p < 0.01 ) . In study phase 1 ( 29 patients ) , cardiac index and myocardial contractility ( ejection fraction ' and mean rate of internal fiber shortening , Vcf ) were determined by echocardiography during the first 48 hours postburn . Cardiac index was lower in the 12-to 24-hour postburn interval in the crystalloid group , but this difference between treatment groups had disappeared by 48 hours postburn . Ejection fractions were normal throughout the entire study , while Vcf was supranormal ( p < 0.01 vs. normals ) and equal in the two resuscitation groups . In study phase 2 ( SO patients ) , extravascular lung water and cardiac index were measured by a st and ard rebreathing technique at least daily for the first postburn week . Lung water remained unchanged in the crystalloid-treated patients ( p > 0.10 ) , but progressively increased in the colloid-treated patients over the seven day study ( p < 0.0001 ) . The measured lung water in each treatment group was significantly different from one another ( p < 0.001 ) . Cardiac index increased progressively and identically in both treatment groups over the study period ( p < 0.01 ) . These data refute the existence of myocardial depression during postburn resuscitation and document hypercontractile left ventricular performance . The addition of colloid to crystalloid resuscitation fluids produces no long lasting benefit on total body blood flow , and promotes accumulation of lung water when edema fluid is being reabsorbed from the burn wound Abstract . The objective of this study was to compare the cardiac and hemodynamic responses to a rapid infusion of 1000 ml of modified fluid gelatin ( group A ) or 1000 ml of lactated Ringer 's solution ( group B ) in emergency room patients suffering from shock . This prospect i ve , r and omized , open , noncrossover study was performed at a medical center university hospital in a surgical resuscitation room in the emergency department . The subjects were 34 patients with either hypovolemic or neurogenic shock who were admitted to the emergency room . A resuscitation protocol according to Advanced Trauma Life Support ( ATLS ) with an additional central venous line or Swan-Ganz catheters for hemodynamic monitoring was used . Physical parameters and hemodynamic variables were measured at baseline and 15 minutes , 30 minutes , and 1 hour after the infusion of 
    Output:
    
Using starches , dextrans , albumin or FFP ( moderate-certainty evidence ) , or gelatins ( low-certainty evidence ) , versus crystalloids probably makes little or no difference to mortality .