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DR. Dr. Ike Sri Redjeki, Sp.AN-KIC Alamat Kantor : SMF/Dept.Anestesiologi & Terapi Intens FKUP/RSHS Jl. Pasteur No. 38 Bandung 40161 Telp/Fax Kantor :

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Presentation on theme: "DR. Dr. Ike Sri Redjeki, Sp.AN-KIC Alamat Kantor : SMF/Dept.Anestesiologi & Terapi Intens FKUP/RSHS Jl. Pasteur No. 38 Bandung 40161 Telp/Fax Kantor :"— Presentation transcript:

1 DR. Dr. Ike Sri Redjeki, Sp.AN-KIC Alamat Kantor : SMF/Dept.Anestesiologi & Terapi Intens FKUP/RSHS Jl. Pasteur No. 38 Bandung Telp/Fax Kantor : / Alamat Rumah : Komplek Permata Indah E-12 Bandung Telp/Fax rumah : No.HP : Tempat/Tgl Lahir : Jakarta, 16 Desember Profesi : Dokter Spesialis Anestesi Jabatan : 1. Kepala SMF/Dept.Anestesiology&Terapi Intensif FKUP/RSHS 2. -

2 Fluid Resuscitation and Transfusion for Trauma Ike Sri Redjeki RS Hasan Sadikin/ FK. UNPAD Bandung

3 When Fluid Resuscitation is Needed ? In SHOCK !

4 SHOCK INADEQUATE CARDIAC OUTPUT Peripheral circulatory failure True Hypovolaemia Blood loss Plasma loss Saline loss Dehydration Apparent Hypovolaemia (vasodilation) Sepsis Neurogenic Anaphylaxis Adrenal insufficiency “ Pump Failure” Cardiogenic Pulmonary Embolus Tamponade Tension pneumoTx

5 Concept of pathogenesis of physiologic changes in Multiple Trauma Trauma Inflammation Haemorrhage  Fibrinolysis Shock Tissue Hypoxia and Acidosis Activation of haemostasis & endothelium Coagulopathy

6 Primary Survey Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms ABCDEs of trauma care – AAirway and c-spine protection – BBreathing and ventilation – CCirculation with hemorrhage control – DDisability/Neurologic status – EExposure/Environmental control In Trauma Patients

7 What is the Recommendation ? ( Sphan et al critical Care 2013,17:R76) Initial resuscitation and prevention further bleeding Minimal elapsed time – The time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control – Grade 1A – Adjunct touniquet use to stop life threatening bleeding from open extreemity injuries in the pre surgical setting – Grade 1B

8 What is the Recommendation ? ( Sphan et al critical Care 2013,17:R76) Patients presenting with haemorrhagic shock and an unidentified source of bleeding undergo immediate further investigation – Grade 1B Chest Abdominal cavity Pelvic ring Further CT  for haemodynamically stable patient

9 What is the Recommendation ? ( Sphan et al critical Care 2013,17:R76) It is not recommended the use of single Hct measurement as an isolated laboratory marker of bleeding – Grade 1B Serum lactate or base deficit measurement as sensitive test to estimate and monitor the extent of bleeding and shock – Grade 1B Routine practice to detect post traumatic coagulopathy include the early, repeated and combined measurement of PT, APTT, fibrinogen and platelets – Grade 1C

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11 Recommendation of Fluid Therapy in Trauma Patients Fluid therapy  be initiated in the hypotensive bleeding trauma patient – Garde 1A Crystalloids  first choice – Grade 1B Avoid hypotonic solution  RL sol Coloids used  within the prescribed limit for each solution Hypertonic solution  for unstable penetrating torso trauma – Grade 2C

12 Recommendation of Fluid Therapy in Trauma Patients Administration of vasopressors  to maintain to target MAP  if no response to fluid therapy – Grade 2C Or inotropic  myocardial dysfunction Maintain temperature > 35 degree C – Grade 1C Target Hb  7 – 9 gr%

13 Damage control resuscitation is now the predominant focus upon arrival in hospital Crystalloid delivery should be minimized, as it can be associated with harm

14 Trauma-induced coagulopathy is a common problem caused by dilution and consumption of clotting factors, hypothermia and acidosis Evidence suggests it can be decreased by early delivery of blood products

15 The best resuscitation appears to be with whole blood rather than component therapy Can 1:1:1 ( Plasma : RBC : Platelets ) ever be an adequate substitute for fresh whole blood, or should blood banks consider a return to using whole blood? Tranexamic acid  should be consider and is significantly cheaper ( compare to Factor VII )

16 Giving unnecessary plasma and platelets should be discouraged in order to reduce the risk of transfusion- related acute lung injury Poin of care  coagulation tests may aid decision making and reduce unnecessary transfusionst of care

17 Massive transfusion protocols, improve communication and delivery of blood products to the patient Enable clinicians to give fresh plasma up front, rather than giving red blood cells initially and plasma later

18 How about Crystalloid ? Giving a significant amount of crystalloid upfront on admission  a common practice  leading to various problem : Abdominal compartment syndrome ( ACS ), Acute Resp Distress Syndrome (ARDS ), multiple organ failure Giving crystalloid > 1.5 liters in emergency department  independent risk factor for mortality > 70 years old  OR 2.89 and Non elderly patients  OR 2.09 High volume ( > 3 liters )  > 70 years  OR 8.61, Using Colloid  decreased lactate level and < renal injury  better tissue resuscitation

19 Transfusion Strategy Masive transfusion : > 10 unit RBc within 24 hour A significant advantage of Warm Fresh Whole Blood over component therapy  contain full amount of platelets Even vs best practice  component therapy 1: 1:1 Fresh Whole Blood >> effective than Component

20 Damage control resuscitation (on admission) Rapid control of surgical bleeding Early and increased use of red blood cells, plasma and platelets in 1: 1: 1 ratio Limitation of excessive crystaloid use Prevention and treatment of hypothermia, hypocalcemia, and acidosis Hypotensive resuscitation strategies Sphan et al Critical Care 2013; 17:R76 – 1-45

21 Current recommendation for blunt trauma is to administer just enough fluid to maintain perfusion Rapid, high-volume fluid administration is discouraged Recommendation : Target BP systolic  80 – 90 mmHg, until major bleeding stop  afterwards optimalized In patients combined haemorragic shock and severe TBI (GCS 80 mmHg

22 Permissive Hypotension in Traumatic Brain Injury Oxygenation and Blood Pressure – Hypoxemia (<90% SpO 2 ) and/or hypotension (<90 mm Hg systolic) are associated with poor outcomes. – Pulse oximetry and blood pressure must be monitored. – Continuous waveform capnography beneficial CPP = MAP- ICP Slightly higher systolic pressure may be required to maintain CPP in TBI

23 Target of Fluid Ressuscitation DO2 = ( CO x Hb x SpO2 x 1.34 ) + (PaO2 x 0,003) ↓ O2 Balance  O2ER= VO2 / DO2 = 25% ↓ VO2 = O2 Consumption

24 CONTROL CENTER IN THE MICROENVIRONMENT Glycocalyx

25 Structure of Glyccocalyx Reitsma S, et al. Eur J Physiol 2007; 454:345–359 Glycocalyx Endothelial cell

26 Protect the Vessel Wall ELECTRONE MICROGRAPH OF MYOCARDIAL CAPILLARY Gouverneur M, Van den berg B, Nieuwdorp M, Stroes E, Vink H. Journal of Internal Medicine 2006; 259: 393–400

27 Alteration of Glycocalyx leads to extravasation Alteration in the composition of the glycocalyx following exposure to an inflammatory insult is one of the earliest features of endothelial activation It is now accepted that TNFα, oxidised lipoproteins, lipopolysaccharide, thrombin, ischaemia/reperfusion, hyperglycaemi a and growth factors all cause glycocalyx disruption via the action of proteases Hypervolemia ↓ Leads to disruption of the glycocalyx

28 Conclusion First hour of trauma management  ABC’s  primary survey and secondary survey being accomplished as fast as possible The time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control Damage control resuscitation  on admission Shock in trauma cases mostly hypovolemia  restore the iv volume Fluid resuscitation  avoid further damage Keep the blood pressure not to high before hemorrhage being controlled Avoid hypervolemia Target of resuscitation  balance between DO2 and VO2

29 Conclusions Blood transfusion  Masive transfusion can be predicted ( BE -10 and Hb Prefer to use WFWB  than blood component Blood component  1 : 1 : 1 Use plasma first  to prevent traumatic coagulopathy

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