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Waldemar Machała Principles of fluid therapy in a massive trauma and hemorrhage. Department of Anesthesiology and Intensive Care The Military Teaching.

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Presentation on theme: "Waldemar Machała Principles of fluid therapy in a massive trauma and hemorrhage. Department of Anesthesiology and Intensive Care The Military Teaching."— Presentation transcript:

1 Waldemar Machała Principles of fluid therapy in a massive trauma and hemorrhage. Department of Anesthesiology and Intensive Care The Military Teaching Hospital-CSW The gen. bryg. Stefan Hubicki Military Center of Medical Education

2 Estimated blood volume (EBV) AgeVolume (mL/KG) Premature100 Newborn90 Pre-school80 School-age75 Adult70 Hematocrit – 40% Hematocrit RBC (PRBC) – on average approx. 60% Miller’s Anesthesia, 7 th edition. 2010: chapter 82. A practice of anesthesia for infants and children, 4 th edition: chapters 8 and 10. C Cote

3 Loss of 1.5 mL of blood/KG/min. for 20 mins. Loss of 150 mL of blood/min. within 1 hr. Transfusion of 50 % of circulating blood volume within 3 hrs. Transfusion of one volume of circulating blood within 24 hrs. Hemorrhage / transfusion Keel M et al: Pathophysiology of trauma. Injury 2005; 36:

4 Shock 1.Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, Plenum Press. 2.Rodriguez RM, Rosenthal MH: Etiology & Pathophysiology of shock. W: Murray MJ, Coursin DB, Pearl RG, Prough DS. eds. Critical care medicine - Perioperative management. Lippincott William & Wilkins, London. 2003; State of inadequate oxygen supply to cells University of Wisconsin Department of Surgery. Circulatory collapse National Institute of General Medical Sciences. Hypovolemic. Obstructing. Cardiogenic. Distributive.

5 Hypovelemic shock Hinshaw, Cox 1972 Hemorrhagic. Visible. Invisible. Non-hemorrhagic. 1.Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, Plenum Press. 2.Rodriguez RM, Rosenthal MH: Etiology & Pathophysiology of shock. W: Murray MJ, Coursin DB, Pearl RG, Prough DS. eds. Critical care medicine - Perioperative management. Lippincott William & Wilkins, London. 2003;

6 Blood loss resulting from bodily injuries Lung: 1000 mL (each side) Liver: 2000 mL Pelvis: >5000 mL Thigh: 2000 mL Crus: 1000 mL Arm: 800 mL Spleen: 2000 mL Forearm: 400 mL

7 Basics for fluids tranfusion after the trauma 1.Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: O 2 flow = [CO X Hgb X SaO 2 X k] + [CO X PaO a x 0.003] The quickest possible restoration of tissue oxygenation. Causing the smallest possible biochemical abnormalities. Protection of renal functions. Avoiding fluids transfusion-related complications.

8 Time for fluid therapy onset 1.Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: Pre-hospital. Hospital emergency ward. During emergency operations. In ICU.

9 On-site activities US Army Wilson WC, Grande CM, Hoyt DB in: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Healthcare USA

10 Scoop and run. Stay and play (stay and treat). On-site strategy of handling the injured Basic life-saving actions Advanced life-saving actions Spine immobilization. Fractures immobilization. Dressing external hemorrhage. Bag mask ventilation. Final securing of the airways. Decompression of pneumothorax. Coniotomy/ tracheotomy. IV access and fluids transfusion. 1.Berlot G, Bacer B, Gullo: Controversial aspects of the prehospital trauma care. Crit Care Clin 2006; 22: Haas B, Nathens AB: Pro/con debate: is the scoop and run approach the best approoach to trauma services organization? Critical Care 2008; 12: 224 (http://ccforum.com/content/12/5/224.http://ccforum.com/content/12/5/224

11 In certain situations, starting rescue actions on site may prolong the time of definite life-saving actions onset 1,2,3 : Attempts of artificial airways – instead of bag mask ventilation and transportation to the hospital. Worse (adverse) result of therapy (next to statistically more frequent occurrence of coagulopathy and multiorgan failure) with the patients who were secured with vascular angioaccess and fluids transfusion and who: Were diagnosed with penetrating bodily trauma 4,5. Were not secured as far as the hemorrhage site is concerned 6. On-site actions Scoop and run, or Stay and play? 1.Berlot G, Bacer B, Gullo: Controversial aspects of the prehospital trauma care. Crit Care Clin 2006; 22: Haas B, Nathens AB: Pro/con debate: is the scoop and run approach the best approoach to trauma services organization? Critical Care 2008; 12: 224 (http://ccforum.com/content/12/5/224.http://ccforum.com/content/12/5/224 3.Bulger EM, Maier RV: Prehospital care of the injured: what’s new. Surg Clin North Am 2007; 87: Bickell WH, Wall MJ Jr, Pepe PE i wsp.: Immediate vs delayed fluid resuscitation for hypotensive patients with penetrating torso injures. N Engl J Med. 1994; 331: Ivatury RR, Nallathambi MN, Roberge RJ i wsp.: Penetrating thoracic injures: in-field stabilization vs prompt transport. J Trauma 1987; 27: Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25:

12 With the patients: With no possibility of final (temporary) hemorrhage securing 1,2,3 : Ectopic pregnancy. Placenta previa. Premature placental disruption. Penetrating injuries (vascular injuries in 90%) 4. Internal hemorrhage. In urban conditions. In the circumstances when the ETA to the hospital is relatively short (4-12 mins.) 5,6. No attempts to cannulate the vessel or fluids transfusion should be made; instead: The patient should be transported to the hospital a.s.a.p. The hospital should be informed about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist). On-site actions Scoop and run, or Stay and play? 1.Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: vs J Trauma 2008; 64: Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204: Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61: Sanchez GP, Peng EWK, Marks R i wsp.: Scoop and run strategy for a resuscitative sternotomy following unstable penetrating chest injury. Interacive Cardiovasc Thorac Surg 2009; 10: Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4:

13 With the patients with no possibility of final (temporary) hemorrhage securing 1,2,3 no attempts to cannulate the vessel or fluids transfusion should be made, instead: The patient should be transported to the hospital a.s.a.p.. The hospital should be informed about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist). On-site actions Scoop and run, or Stay and play? 1.Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: vs J Trauma 2008; 64: Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204: Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61: Adverse effects of fluids transfusion with the lack of securing the hemorrhage site: Increased bleeding from damaged vessels. Smaller clot-forming abilities in the site where the vessels are damaged. Increase in the hematocrit and the hemoglobin levels. Lowering of the clotting factors levels. Risk of hypothermia.

14 On-site actions Scoop and run, or Stay and play? 1.Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: vs J Trauma 2008; 64: Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204: Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61:

15 With the patients whose hemorrhage was temporarily secured, e.g. by applying: 1,2, : Pressure dressing. Tourniquet. Polymer dressing (e.g. Quick-Cloth). you should: Secure two peripheral vascular angioaccess points (14G). Apply infusion of 0.9% NaCl, or lactatad Ringer’s solution (1000 mL) – if SAP< 90 mm Hg (or 110 mm Hg – cerebral injuries). Maintain MAP: mm Hg. In acute hypovolemia pathophysiology, decrease in preload prevails – hence, the only purposeful action is intravascular volume replacement. Catecholamines increase afterload and are not recommended at this stage of shock. Transport the patient to the hospital. Inform the hospital about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist). On-site actions Scoop and run, or Stay and play? 1.Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.

16 With the patients whose hemorrhage was temporarily secured, e.g. by applying: 1,2,: Pressure dressing. Tourniquet. Polymer dressing (e.g. Quick-Cloth). You should: Secure two peripheral vascular angioaccess points (14G). Apply infusion of 0.9% NaCl, or Ringer’s solution (1000 mL) – if SAP< 90 mm Hg (or 110 mm Hg – cerebral injuries). Keep MAP: mm Hg. In acute hypovolemia pathophysiology decrease of preload prevails – hence, the only purposeful action is intravascular volume replacement. Catecholamines increase afterload and are not recommended at this stage of shock. Transport the patient to the hospital. Inform the hospital about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist).. On-site actions Scoop and run, or Stay and play? 1.Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5. Watch out for: Pain. Pain. lactated Psychomotor agitation. (result of hypoxia)

17 On-site actions Scoop and run, or Stay and play? 1.Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.

18 On-site actions US Army In such circumstances, we may: Allow for hypotension +/- ?. Avoid hemorrhage volume increase. Consider small volume resuscitation (SVR). 1.Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA Rekomendacje dla podawania stężonej soli w HAES w NATO -

19 Alternative in fluid therapy? 1.Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscytation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA Rekomendacje dla podawania stężonej soli w HAES w NATO -

20 On-site actions hemorrhage stopped but co-existing shock HyperHAES because: Instant increase of arterial blood pressure and cardiac output, with decreased systemic vascular resistance (SVR). Instant microcirculation flow increase. Lowering adverse effects of ischemia and reperfusion. Increase of diuresis resulting from improved organ perfusion. Increase in survival ratio. Kreimeier i Messmer – experimental and clinical studies.

21 HyperHAES … HyperHAES → 6% HAES (200/ 0.5) + 7,2% NaCl HyperHAES → 6% HAES (200/ 0.5) + 7,2% NaCl → 250 mL bags. Na mmol/ L. Cl mmol/ L. pH3.5 – 6.0. Osmolarity:2464 mOsm/ L. COP36 mm Hg. Dosage:4 mL/ KG (approx. 250 mL). Infusion volume:2 – 5 minutes.

22 HyperHAES - effects … Hypertonic solution of NaCl quickly increases circulating blood volume through transferring the fluid from extravascular to intravascular space. 7.2% NaCl included in the HyperHAES solution is responsible for inducing the mechanism of quick endogenous fluid transfer. Colloid present in the solution binds water which ensures long-lasting volume effect. Endogenous water is mobilized mainly from the area of erythrocytes and vascular endothelial cells: Circulating blood volume is rapidly increased (3 – 4x of the transfused volume). Microcirculation flow appears through endothelial cells dehydration thus increasing oxygen supply to tissues.

23 Ideal solution for fluid resuscitation: … Transfusion of small volume improves perfusion. Beneficial effect on oxygen extraction in tissues: Oxygen supply. Oxygen use. Proper composition taking into account pH measure and electrolyte composition. Sterility. Suitably long effects. Stability. Ready to use. Inexpensive.

24 Crystalloids …

25 Colloids … PlasmaHemohes – 6% Voluven (Fresenius-Kabi) Tetraspan (BBraun) Volulyte (Fresenius-Kabi) Hextend (Hospira) – pH: 5.9 Na + (mmol/ L) K + (mmol/ L) Ca 2+ (mmol/ L) Mg 2+ (mmol/ L) Cl - (mmol/ L) HCO3 - (mmol/ L) Lactate (mmol/ L) Acetate (mmol/ L) Malate (mmol/ L) Osmolarity (mOsm/ L) Colloid (g/ L)Protein 30-52Starch 60

26 Crystalloids vs. colloids volume effect … Transfused volume [mL] Type of infusion fluidIncrease in plasma volume [mL] 10005% glucose Lactated Ringer’s solution 250 7,5% NaCl % Albumins % Albumins Volulyte500

27 Time to start fluid therapy 1.Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: Pre-hospital. Hospital emergency ward. During emergency operations. In ICU.

28 Recognize the shock paying attention to possible problems: Co-existing CNS injury. Age. Body build (athletic). Medication taken. Hypothermia. Pacer. Clothes (waterproof; Velcro). Hospital activities 1.Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: Stop the bleeding – great ‘five’ of hemorrhages: External: Clinical examination. BP monitoring. Chest: Clinical examination and chest X-ray. Pulmonary drainage. Abdomen: Clinical examination. DPO, FAST, CT, laparoscopy, laparotomy. Pelvis: Clinical examination. X-ray, CT, angiography. Long bones.

29 Hospital activities US Army Rescue actions depending on response to fluid resuscitation (to fast transfusion) : 2000 mL of lactated Ringer’s solution (adults). 20 mL/KG of lactated Ringer’s solution (children). ChangesQuick responseTemporary responseLack of reaction Vital functionsReturn to correct valuesTemporary improvement after which ↓BP and ↑HR Incorrect values maintained Estimated blood loss10-20%20-40%>40% Necessity to infuse larger volume of crystalloids Hardly possibleHighly probable Necessity to transfuse bloodHardly possibleLikelyNecessary Necessity to transfuse blood components Hardly possibleHighly possibleNecessary transfusion in emergency mode Necessity for the surgical intervention PossibleProbableNecessary Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA

30 Purpose of fluid therapy US Army Concerns exclusively young and healthy people without co-existing CNS injury. Early resuscitations ends with final securing of the hemorrhage spot. ParameterEarly purposeLate purpose SAP90 mm Hg> 100 mm Hg HR< 120/ min.< 100/ min. Hct> 25%> 20% LactatesValues lower than those after the first examination Normal CODependant upon arterial blood pressurePossibly high RKZNo respiratory acidosis. Permitted metabolic acidosis Normal Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA

31 Platelet count: < pts. 50 – pt. Fibrinogen: < 1g/L1 pt. D-dimers: > 4 mg/L3 pts mg/L2 pts. INR: >2,32 pts pts. DIC and ACoTS criteria 1,2 1.Johansson PI, Sorensen AM, Perner A i wsp.: Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study. Critical Care 2012; 15: Taylor FB, Jr, Toh CH, Hoots WK i wsp.: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001; 86: Criteria for diagnosing DIC: ≥ 5 pts. Criteria for diagnosing acute coagulopathy of traumatic stress (ACoTS): APTT or/and INR: >35 secs. or 1.2. Coagulopathy (on-site/ in the hospital) 4,5,6 : Acute coagulopathy of traumatic stress (ACoTS). Disseminated intravascular coagulation (DIC).

32 Because coagulation disorders appear as a result of: Hemorrhage. Traumatic stress. And are worsened: Resulting from physical status (co-existing illnesses). After infusion of 2000 mL of fluids. And are further increased in the course of: Hypoperfusion with all its consequences. Hypothermia. Acidosis. Hypercatecholaminemia. Electrolyte imbalance. Why is the discussion about DIC and ACoTS so important? 1,2,3 1.Johansson PI, Sorensen AM, Perner A i wsp.: Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study. Critical Care 2012; 15: Taylor FB, Jr, Toh CH, Hoots WK i wsp.: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001; 86: Shaz BH, Winkler AM, James AB i wsp.: Pathophysiology of early trauma-induced coagulopathy: emerging evidence for hemodilution and coagulation factor depletion. J Trauma 2011; 70:

33 Monitoring clinical indicators denoting proper perfusion Marik PE, Monnet X, Teboul JL: Hemodynamic parameters to gouide fluid therapy. Annals of intensive care 2011; 1: 1. Mean arterial pressure. Perfusion pressure: cerebral and visceral: State of consciousness. Diuresis. Capillary refill. Peripheral perfusion (mottled skin). Temperature of peripheral body parts (cold feet, hands). Lactates concentration. Gasometry (pH, BE, HCO 3 - ). Mixed venous oxygen saturation (SvO 2 ). CO 2 partial pressure in mixed venous blood. CO 2 partial pressure in tissues (StCO 2 ). O 2 partial pressure in muscles (StO 2 ).

34 Blood transfusion Miller’s Anesthesia, 7 th edition. 2010: chapter 82. A practice of anesthesia for infants and children, 4 th edition: chapters8 and 10. C Cote Indications for transfusion: Ischemia, Hgb < 7 g/dL. Hematocrit < 25%. Elderly patients with co-existing cardiac disease. Increased oxygen demand. Maintained Hgb levels: 7-9 g/dL.

35 Loss of the circulating blood volume (EBV – estimated blood volume) Hematocrit– 40% Hematocrit RBC (PRBC) – on average approx. 60% Crucial transfusion parameters Product nameDosageTransfusion result Erythrocyte concentrate10-15 mL/KGHemoglobin  2-3 g/dL Erythrocyte concentrate1 unitHematocrit  by approx. 3%. Thrombocyte concentrate5-10 unitsPlatelets  – /mm 3 Fresh frozen plasma10 – 15 mL/KGCoefficient  15-20% Kryoprecipitate1-2 units/KGFibrinogen  mg/dL Miller’s Anesthesia, 7 th edition. 2010: chapter 82. A practice of anesthesia for infants and children, 4 th edition: chapters 8 and 10. C Cote

36 End of fluid resuscitation Effective oxygen therapy resulting in the increase of SpO 2 >97%. Mechanical intubation and ventilation: Protection of lower airways: Resolving of oxygenation abnormalities (FiO 2 97%). Resolving of ventilation impairments (ETCO 2 <60 mm Hg). Replenishment of circulating blood volume (colloids, crystalloids, blood products): CVP approx. 20 cm H 2 O. Hgb: g/dL. Positive result of implemented therapy (including catecholamines) resulting in: HR within: /min. MAP within: mm Hg. Increase in the value of ScvO 2 >65%. Decrease in lactates concentration <2 mmol/L.

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