“FLUID AND BLOOD RESUSCITATION IN ABDOMINAL TRAUMA:

IMPORTANT TIPS IN CLINICAL PRACTICE FOR SURGEONS”

Dr. T.C. KriplaniProfessor & HeadDepartment of AnaesthesiologyNSCB Medical CollegeJABALPUR (M.P.)

American College of Surgeons Classes of Acute Hemorrhage

Factors I II III IV

Blood loss <15%(<750ml)

15-30%(750-1500ml)

30-40%(1500-2000ml)

>40%(>2000ml)

Pulse >100 >100 >120 >140

B.P. Normal Normal ↓ ↓↓

Pulse pressure N or ↓ ↓ ↓↓ ↓↓

Capillary refill <2s 2-3s 3-4s >5s

Resp. rate 14-20 20-30 30-40 >40

Urine output ml/hr 30 or more 20-30 5-10 Negligible

Mental status Slightly anxious Mildly anxious Anxious & confused

ConfusedLethargic

Response to blood loss• ↓Blood volume.• ↓Hydrostatic pressure in capillaries.• Fluid moves from interstitial space to intravascular

space.• Activation of Renin-Angiotensin Aldosterone system.• Na+ retained by kidneys.• α response causes vasoconstriction which shunts

blood from skin, viscera & muscle to preserve blood flow to vital organs.

Asses the loss quickly on clinical grounds

• If the loss is about 750ml(15%) & patient is haemodynamically stable.

• KVO (Keep the Vein Open)• No fluid required.

• If the loss is about 1500ml(30%) & B.P. 70 - 90mmHg, but stable,

• Start crystalloid solution.• Give oxygen.• Do not raise B.P.(Permissive Hypotension)

If the loss is 1500-2000ml(30-40%)

• Give crystalloids first, about 2 litres followed by colloid.

• Asses oxygenation of vital organs.• Give oxygen.• Think of blood transfusion.

If the loss is >2000ml(40%)

• Start crystalloid and colloid.• Give oxygen.• Start blood transfusion.• Monitor oxygenation.• Bring Hb to 7gm%.

Which crystalloid is better?• Only 25% remain in intravascular compartment.• Dilutional coagulopathy, interstitial & chances of pulmonary edema.

Crystalloid Osmolarity PH Remarks Recommendations

Dextrose 5% 252 4.5

Hypotonic, glucose taken up by cells & water produces oedema.Low PH, ↑blood sugar-brain ischemia.↑CO2 production, ↑lact. Production

NEVER BE USED

Saline 0.9%308(Na 154, Cl 154meq/L)

5.7 Low PH.Hyperchloraemic acidosis is produced. NOT IDEAL

Saline 7.5% 2567(Na 1283, Cl 1283) 5.7

Vol. Exp(250ml→1235ml)Interstitial & cellular dehydration.Rapid rate dangerous.

NOT DESIRED

Lactated Ringer’s solution

273(Na 130, Cl 109, K 4, Ca 3, lactate 28)

6.4Osmolarity near bloodLactate act as buffer.Converted to bicarbonate

BETTER

Normosol

295(Na 140, Cl 98, K 5, Acetate 27, Mg 3)

7.4 Mg. can counteract compensatory vasoconstriction NOT DESIRED

Which colloid is better?

Albumin Oncotic pressure mm of Hg Vol. expansions Half life

5% 20 70-100% 16-24 hrs

20% 70 300% 16-24 hrs

25% 100 500% 16-24 hrs

• Costly • Allergic reactions• Infection may be transmitted.• Transport of drugs & endogenous substances.

(NOT PREFERRED)

Synthetic colloids

• Gelatins.• Dextrans.• Starch (HES)

GELATINS• Prepared by hydrolysis Bovine/Beef collagen.

Mol.wt.(Da)• Haemaccel (Urea linked) 3.5% 30,000

(Na 145, Cl 145, K 5.1, Ca 6.25)• Gelofusine (Succinylated) 4% 35,000

(Na 154, Cl 125)• Cross linked 5.5% 30,000

• PH, osmolarity, COP – Near to blood.• Vol. expansion 70-80%, half life 1-3hrs.• No dose limit, ?Renal damage.• Anaphylaxis .03%, Minor reactions 21%.• WHO has listed Gelatins as essential drug.• Use abandoned in U.S.A. from 1978.• Not approved by F.D.A.• Use has drastically decreased.

DEXTRANS• Biosynthesized from sucrose by bacteria

leuconostoc messenteroides.• Dextran 70 (6%)

• Osmolarity 280-324• COP 20-30 mm of Hg.• Vol.Exp. 100%• Half life 5-6hrs.• Max. dose(daily) 1.5gm/kg.

• Anaphylactoid reaction, Allergic reaction• Interference with cross matching.• ↑ bleeding tendency.

NOT USED NOW

DEXTRAN 40 (10%) (Lomodex, Plasmex-40)• Available in normal saline or in 5% dextrose.• Dose 8-10ml/kg/day.

• Osmolarity 280-324• COP 40-60 mm of Hg.• Vol.Exp. 150-200%• Half life 3 hrs.

• Anaphylactoid reactions, allergic reactions.• Interference with cross matching.• Maximum volume expansion.• May produce severe cellular dehydration.• Reduce blood viscosity, improves tissue perfusion.

AT TIMES USED TO IMPROVE MICROCIRCULATION

STARCH (Hydroxy Ethyl Starch)H.E.S.

• Made from Amylopectin(Hydrolysis & Hydroxy-ethylation).

• Derived from maize or sorghum or potatoes.• Can be classified into

• High molecular wt. (1st Generation)(4,50,000)

• Medium MW (2nd Generation)(2,00,000 – 1,30,000)

• Low MW (3rd Generation)(70,000)

Physiochemical properties of different H.E.S. preparations

HES 70/.5

HES 130/.4

HES 200/.5

HES 200/.5

HES 450/.7

Concentration 6% 6% 6% 10% 10%

Oncotic pressure mm. of Hg 30-36 36 30-37 55-60 25-30

Volume expansion 100% 100% 100% 130% 100%

Half life (hrs) 1-2 2-3 3-4 3-4 5-6

Maximum dose ml/kg 33 50 33 33 20

Effect on hemostasis 0 Negligible + ++ +++

H.E.S.(Contd.)• HES 130/.4 improves tissue perfusion and

oxygenation.• May ameliorate capillary leakage.• Hyperviscosity of urine. ? Renal tubular damage.

But 130/.4 is safe.• Some H.E.S. is taken up by reticuloendothelial

system and induce pruritis.• PH around 5.5.(Acidic)• H.E.S. 130/.4 is preferred colloid at present.

Indications of Blood Transfusion

• Human tolerance to Acute Normovolemic Blood loss is about Hb 7gm%.(21-25% HCT).

• Start blood transfusion if blood loss > 30-40%.• FWB(Fresh Warm Blood) is preferred.

(Experience of American Medics in Afghan & Iraq war 6000 units of FWB was transfused)

(Crit Care Med. July 2008)• Beware of complications of massive blood

transfusion.

MOST IMPORTANT IS CLINICAL MONITORING

1. B.P. (Invasive more reliable in shock) Radial +(80), Brachial +(70), Carotid +(60) Pulse : Volume

2. Capillary refill time goes on ↑.3. Hb estimation unreliable in acute blood loss.

(may take 8-12hrs to stabilise)4. C.V.P. (may not change upto 30% loss)5. Urine output (hrly.)

(Lack of urine output in acutely hypovolemic patient is renal success, not renal failure)

CLINICAL MONITORING(Contd.)6. Measure O2 extraction (good marker of hypovolemic shock)

Pulse oximetry SVO2Normal >95% >65Mild hypovolemia >95% 50-65Severe hypovolemia >95% <50• O2 extraction of >50%. Hypovolemic shock usually lactate > 4m.mol/L.

7. End Exp. CO2 (through nasal prongs) gives online measure of success or failure of volume resuscitation.(If pulmonary circulation decreases, End Exp.CO2 goes on decreasing)

8. Bicarbonate estimation is a good marker of tissue perfusion and oxygenation.• Normal BE ± 3 m.mol/L• Mild base def. -2-5 m.mol/L• Moderate -6-14 m.mol/L• Severe >-15m.mol/L

BEWARE OF LETHAL TRIAD

• Hypothermia• Acidosis • Coagulopathy