Transcript Fluid Resuscitation in Trauma

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 : 022-2036285/022-2038306
Alamat Rumah
: Komplek Permata Indah E-12 Bandung
Telp/Fax rumah : 022-6031526
No.HP
: 0811230514
Tempat/Tgl Lahir : Jakarta, 16 Desember 1950
Email
:-
Profesi
: Dokter Spesialis Anestesi
Jabatan
:
1. Kepala SMF/Dept.Anestesiology&Terapi Intensif FKUP/RSHS
2. -
Fluid Resuscitation and Transfusion
for
Trauma
Ike Sri Redjeki
RS Hasan Sadikin/ FK. UNPAD
Bandung
When Fluid Resuscitation is Needed ?
In SHOCK !
SHOCK
Blood loss
True
Hypovolaemia
Sepsis
Apparent
Hypovolaemia
(vasodilation)
Pump
Failure”
“
Saline loss
Dehydration
Peripheral
circulatory
failure
INADEQUATE
CARDIAC
OUTPUT
Plasma loss
Cardiogenic
Pulmonary Embolus
Tamponade
Tension pneumoTx
Neurogenic
Anaphylaxis
Adrenal
insufficiency
Concept of pathogenesis of physiologic changes in
Multiple Trauma
Trauma
Inflammation
Activation of
haemostasis &
endothelium
Haemorrhage 
Shock
Tissue Hypoxia and
Coagulopathy
Acidosis
Fibrinolysis
Primary Survey
In Trauma
Patients
• Patients are assessed and treatment priorities
established based on their injuries, vital signs, and
injury mechanisms
• ABCDEs of trauma care
–A
–B
–C
–D
–E
Airway and c-spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability/Neurologic status
Exposure/Environmental control
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
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
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
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
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%
• Damage control resuscitation is now the predominant
focus upon arrival in hospital
• Crystalloid delivery should be minimized, as it can be
associated with harm
• 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
• 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 )
• Giving unnecessary plasma and platelets should be
discouraged in order to reduce the risk of transfusionrelated acute lung injury
• Poin of care  coagulation tests may aid decision
making and reduce unnecessary transfusionst of care
• 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
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
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
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
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 < 8)  MAP > 80 mmHg
Permissive Hypotension in
Traumatic Brain Injury
• Oxygenation and Blood
Pressure
– Hypoxemia (<90% SpO2)
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
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
CONTROL CENTER IN THE MICROENVIRONMENT
Glycocalyx
http://www.glycocalyx.nl/background.php
Structure of Glyccocalyx
Glycocalyx
Endothelial cell
Reitsma S, et al. Eur J Physiol 2007; 454:345–359
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
Alteration of Glycocalyx leads to extravasation
• Alteration in the composition of the glycocalyx
Hypervolemia
following exposure
to an inflammatory insult is
one of the earliest features
↓ of endothelial activation
• It is nowLeads
acceptedtothat
TNFα,
oxidised
disruption of the
lipoproteins, lipopolysaccharide, thrombin,
glycocalyx
ischaemia/reperfusion,
hyperglycaemia and
growth factors all cause glycocalyx disruption
via the action of proteases
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
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