Transcript Slide 1

Damage Control Resuscitation
John B. Holcomb, MD, FACS
Professor and Vice Chair of Surgery
University of Texas Health Science Center,
Houston, TX
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Nothing to Disclose
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Texas Trauma Institute
Houston, TX
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Memorial Hermann-TMC
and UT Health
Trauma Volume - 2012
Update slide
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May 2, 2013
• In 2010, there were 5.1 million deaths from injuries
— 10% of all deaths — and the total number of
deaths from injuries was greater than the number
from infection with HIV, tuberculosis, and malaria
combined (3.8 million).
• Overall, the number of deaths from injuries
increased by 24% between 1990 and 2010.
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Years of Potential Life Lost (YPLL)
Before Age 65
Cause of Death
Percent
All Causes
Unintentional Injury
Suicide
Homicide
Malignant Neoplasms
Heart Disease
Perinatal Period
Congenital Anomalies
Cerebrovascular
HIV
Liver Disease
All Others
YPLL
948,426
199,903
52,265
48,190
137,221
107,009
75,496
43,615
21,817
21,508
21,352
220,050
100.0%
21.1%
5.5%
5.1%
14.5%
11.3%
8.0%
4.6%
2.3%
2.3%
2.3%
23.2%
31.7%
The National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System. US Department
of Health and Human Services, CDC; 2008. Available at: http://www.cdc.gov/ncipc/wisqars/. Accessed May 22, 2009.
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UTHSC-Houston 1999-2008
Trauma admissions = 36,028 and 2394 deaths = 6.6%
Early deaths (≤ 24 hrs) = 1398 or 58%
30
25
%
20
15
72 hrs = 72%
24 hrs = 58%
6 days = 92%
30 days = 97%
10
5
0
Deaths from day 31-171 = 68/2394 = 3%
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Bottom Line Up Front
• Crystalloid resuscitation increase blood
loss, transfusion requirements and death
• Balanced blood product resuscitation
decreases blood loss, transfusion
requirements and improves survival
– Must have thawed/liquid plasma in the ED to
really do this well
• Time is critical
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How to Resuscitate?
• Its not just raise the BP
– Not just the hole in the blood vessel that needs rapid suture
• Why do we give RBCs first?
– Red stuff
• Reverse the systemic and iatrogenic endothelial injury
– Reverse permeability
– Prevent edema
– Repair the endothelium
• Dampen the systemic inflammatory response
• Prevent and Reverse coagulopathy
• Time is important
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J Trauma, 2007.
• Rapid progress in trauma care occurs during a war.
• Damage control resuscitation addresses diagnosis and
treatment of the entire lethal triad immediately upon
admission.
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DCR components
•
•
•
•
•
•
•
Stop bleeding
Hypotensive resuscitation
Minimize crystalloid
Use thawed plasma to resuscitate patients
Increased platelet use
Reverse hypothermia and acidosis
Hemostatic adjuncts
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Typical 24 hour Resuscitation
• THEN
– 20 liters of LR
– 15 RBCs
– 5 FFP
– 0 platelets
• NOW
– 3-5 liters of LR
– 7 RBCs
– 6 FFP
– 1 platelets
Associated with decreased edema, MOF
and improved survival
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17 yr, GSW Liver, 60/30, BD-17
•
•
•
•
2010
11 RBC
10 FFP
2 platelet
3 liters
crystalloid
• 3 ops
• Home in 8
days
Rt pulmonary lower lobe wedge,
Rt hepatic lobectomy,
Rt nephrectomy
14 RBC
14 FFP
2 platelets
2 cryo
2 liters
of crystalloid
2014
Post Operative Damage Control
Laparotomy and Thoracotomy
5 days post op
Home day 10
Component Therapy
Component Therapy:
1U PRBC + 1U PLT + 1U FFP + 1 U cryo
680 COLD mL
•Hct 29%
•Plt 80K
•Coag factors 65% of initial concentration
•Armand & Hess, Transfusion Med. Rev., 2003
WWB:
500 mL Warm
Hct: 38-50%
Plt: 150-400K
Coag: 100%
1000 mg Fibrinogen
Which one to use, start, how much, stop ??
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J Trauma, 2007
70
65%
Mortality
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2003-2004, n = 252
P < 0.05
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40
30
34%
16231
20
53
19%
162
10
0
(Low) 1:8
(Medium) 1:2.5
(High) 1:1.4
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Ann Surg 2008
• Multicenter (16) Retrospective Massive Transfusion
Study
• 12 months data collection
• ≈ 30,000 admissions and ≈11,650 transfused
– 466 MT’s
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30 day Kaplan-Meier
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JACS 2010
12 hrs
24 hrs
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Ann of Surg, 2011
2004-2008
vs
2008-2010
DCR in DCL:
• DCR patients received less, (p<0.05).
– crystalloids (14 L vs. 5 L),
RBC (13 U vs. 7 U),
– plasma (11 U vs. 8 U)
platelets (6 U vs. 0 U)
• ALI, AKI, MOF all lower in DCR patients
• 24-hour and 30-day survival was higher in DCR
– (88% vs. 97%, p=0.01 and 76% vs. 86%, p=0.03).
• MTs in the DCL population decreased from 67% to 43% (p<0.01)
• In severely injured patients who underwent DCL; DCR was
associated with both decreased blood product use and improved
survival.
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J Trauma 2009
• Very important paper, not only for this topic, but
all uncontrolled studies
• “They lived long enough to receive a treatment,
not that the treatment caused them to live
longer”
• However at UAB, they don’t give plasma early
– Median of 18 min vs 93 (RBC vs plasma
administration)
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How do you make early blood
products happen?
• Work with the Blood bank and Donor Center
• O- RBCs—in the ED
• AB or A plasma—in the ED
–Thawed or Liquid plasma
• Platelets—in the ED?
• Prehospital?
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JAMA Surg, 2013
• Implementation of a ED-TP protocol:
– Decreased time to first plasma transfusion (89 vs 43
minutes, p.= .001).
• The TP-ED protocol was associated with a reduction in
24-hour transfusion of RBCs (p=.04), plasma (p=.04),
and platelets (p=.001).
• Logistic regression identified TP-ED as an independent
predictor of decreased 30-day mortality (p=.04).
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JAMA Surg 2013
• 3.6% of admissions received a blood transfusion within 6
hours of admission
• Overall mortality was 25%
– 94% of hemorrhagic deaths occurred within 24 hours
• the median time to hemorrhagic death was 2.6 hours,
– range, 1.7-5.4 hours
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Transfused = big mortality
• There were 34,362 trauma admissions in 10
centers over 58 weeks
• 12,560 (36%) highest level activations
• 1245 (10%) were transfused within 6 hours
• 905 (7%) received a transfusion of ≥ 3 RBCs
– 25% mortality
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PROMMTT plasma:RBC
Hem death at 2.6 hrs
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PROMMTT platelets:RBCs
Hem death at 2.6 hrs
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PROMMTT
• Data suggest that earlier and higher ratios
of plasma and platelets were associated
with decreased in-hospital mortality in the
first 6 hours.
– 1:1:1 is superior to 1:1:2
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J Trauma 2013
The incremental amount of crystalloid
rather than the amount of blood
products transfused during the first day of care
seems to be the modifiable risk factor
for lung injury.
TRALI (0) vs CRALI (505)?
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Lots of
work
over a
long
time
All the retrospective studies
Whole Blood vs Components Study
Frozen Blood vs Stored Blood
All funded
by DoD
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J Trauma, 2011
J Trauma 2011
J Trauma 2012
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R-TEG Graphical Display in the ED
• We no
longer send
PT / PTT /
INR,
fibrinogen
and platelet
counts
Ann Surg 2012
UT Health Science Center and
Memorial Hermann Hospital
Houston, TX
Summary
• Considering the speed, charges, and
global functional information obtained,
TEG is superior to CCTs.
– acute care surgery group, emergency
medicine, orthopaedics, anesthesia,
neurosurgery, pediatric surgery
How we use TEG
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•
•
2005-2011, 1412 (4.7%) patients
sustained blunt liver injury.
AAST Grade IV and V injuries
accounted for 244 (17%) patients,
of which 206 patients survived to
leave the ED.
–
•
The DCR cohort had an increase
in successful non-operative
management
–
•
Pre DCR vs DCR
54 to 74%, p<0.01
The DCR treatment cohort
resulted in improved survival
–
73% to 94% (p<0.01).
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Survival of Grade 4 and 5 Liver
Injury over 7 years n = 206
Survival
100
Percentage of patients
90
80
Survival
70
60
2005
2006
2007
2008
Years
2009
2010
2011
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How does plasma “work”?
• Is it all the same?
• Replace lost or consumed coagulation
proteins?
• Stabilize the endothelium?
• Just a better colloid?
• Need some mechanistic work here
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J Trauma 2010
• It is possible that the thousands of proteins in FFP promote vascular
stability through regulation of critical junction proteins.
• Compromise of EC junctions could lead to a number of deleterious
effects:
– barrier dysfunction, interstitial edema, tissue hypoxia, inflammatory cell
infiltration, detached pericytes, extracellular matrix breakdown, apoptosis and
exposed subendothelium.
• We suggest a possible beneficial effect of FFP on hemostasis at the
EC level,
– as opposed to the traditional view of FFP as only a source of clotting factors.
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Fold decrease in
permeability above control
Pulmonary Endothelial Cell Permeability
10
Day 0
Day 5
Day 10
LR
LP
8
6
4
2
0
5%
10
0%
30
%
5%
5%
10
0%
30
%
5%
10
0%
30
%
-4
10
0%
30
%
5%
10
0%
30
%
-2
Findings:
1. Plasma and LP are both Protective against EC permeability
2. LR has no protective effects on EC permeability
3. The protective effects of plasma diminish with time
J Trauma, 2010
Anes & Analg, 2011
The glycocalyx is a ubiquitous barrier that protects the
underlying endothelium and prevents injurious neutrophilendothelial interaction.
A
B
C
D
A = baseline
B= shock
C = LR resus
C = Plasma resus
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Shock 2012
NS
Hextend
FFP
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Stem Cells and Dev 2011
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Prehospital and Hospital
• No distinction
• Should be a seemless continuum
• What works in the hospital should be used
prehospital
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Ann Surg 2013
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RBC and FFP on Helicopters
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•
•
•
•
19 months
4 helicopters
2 units O- and 2 units thawed AB plasma
Indications for transfusion same as in the ED
150 trauma patients
– 90% continued receiving products in the ED
– Improved early survival
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Back to the Future
Lyophilized Plasma Resuscitation
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Dried Plasma in the IDF
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Shock, 2013
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Dried Plasma Product Carried by US
Special Operations Forces
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Different ProCoagulants
Many US Companies
Working on
dried plasma
So what do we do - today
• Identify patients who need resuscitation
– Prehospital and hospital
• Use blood products, not crystalloid or
artificial colloids
• Transfuse in a balanced fashion, starting
with the first units
• Platelets early
• When the rate of transfusion slows,
transition to TEG driven
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Concept
• Not rigidly ratio driven
• Not rigidly TEG (or ROTEM) driven
• Incorporates the elements of time and
logistics and personnel specific to our site
• Plasma is our primary resuscitation fluid
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Summary
• Uncontrolled Hemorrhage is a major problem
• Limit crystalloid, use more plasma and platelets
• Predictive models are here
– Must start components earlier
– Place blood products in the ED
• Do the preclinical and human studies
• Improved study design and analysis
• Mechanistic studies will allow more focused tx
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