Waldemar Machała Principles of fluid therapy in a massive trauma and hemorrhage. Department of...

Waldemar Machała

Principles of fluid therapy in a massive trauma and hemorrhage.

Ghazni, Afghanistan, September 2012

Department of Anesthesiologyand Intensive Care

The Military Teaching Hospital-CSW

The gen. bryg. Stefan Hubicki Military Center of Medical Education

Estimated blood volume (EBV)

Age Volume (mL/KG)

Premature 100

Newborn 90

Pre-school 80

School-age 75

Adult 70

Hematocrit – 40%Hematocrit RBC (PRBC) – on average approx. 60%

Miller’s Anesthesia, 7th edition. 2010: chapter 82.A practice of anesthesia for infants and children, 4th edition: chapters 8 and 10. C Cote. 2009.

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: 691-671.

Shock

1. Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, 1972. 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; 192-205.

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.

Hypovelemic shock Hinshaw, Cox 1972

Hemorrhagic.

Visible.

Invisible.

Non-hemorrhagic.

1. Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, 1972. 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; 192-205.

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

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: 65-70.

O2 flow = [CO X Hgb X SaO2 X k] + [CO X PaOa 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.

Time for fluid therapy onset


Pre-hospital.

Hospital emergency ward.

During emergency operations.

In ICU.

On-site activities US Army

Physical status Conduct

Hemorrhage stopped with no symptoms of shock

No fluids transfusion

Hemorrhage stopped with symptoms of shock

HAES (Hespan) – 1000 mL

Uncontrollable hemorrhage (internal): abdomen, chest


Wilson WC, Grande CM, Hoyt DB in: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Healthcare USA. 2007.

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: 457-468.2. 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

In certain situations, starting rescue actions on site may prolong the time of definite life-saving actions onset1,2,3:

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 trauma4,5.

Were not secured as far as the hemorrhage site is concerned6.

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: 457-468.2. 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. 3. Bulger EM, Maier RV: Prehospital care of the injured: what’s new. Surg Clin North Am 2007; 87: 37-53.4. 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: 1105-1109.5. Ivatury RR, Nallathambi MN, Roberge RJ i wsp.: Penetrating thoracic injures: in-field stabilization vs prompt transport. J Trauma 1987; 27: 1073.6. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.

http://ccforum.com/content/12/5/224

With the patients:

With no possibility of final (temporary) hemorrhage securing1,2,3:

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).


1. Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26.2. 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: 625-632.3. 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: 1366-1372.4. 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: 467-469.5. Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: 265-270.6. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.

With the patients with no possibility of final (temporary) hemorrhage securing1,2,3 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).


1. Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26.2. 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: 625-632.3. 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: 1366-1372.

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.


1. Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26.2. 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: 625-632.3. 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: 1366-1372.

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: 40-50 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).


1. Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: 265-270.2. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.3. Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.

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: 40-50 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)..



Watch out for: Pain. lactatedPsychomotor agitation.

(result of hypoxia)

On-site actions US Army

Physical status Action

Hemorrhage stopped with no symptoms of shock


Hemorrhage stopped with symptoms of shock

HAES (Hespan) – 1000 mL

Uncontrollable hemorrhage (internal): abdomen, chest

No fluids transfusion?

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. 2007.2. Rekomendacje dla podawania stężonej soli w HAES w NATO - http://ftp.rta.nato.int/public/Pubfulltext/RTO/MP/RTO-MP-HFM-109///MP-HFM-109-07.pdf

Alternative in fluid therapy?

1. Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscytation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA. 2007.2. Rekomendacje dla podawania stężonej soli w HAES w NATO - http://ftp.rta.nato.int/public/Pubfulltext/RTO/MP/RTO-MP-HFM-109///MP-HFM-109-07.pdf

?

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.

HyperHAES

…

HyperHAES → 6% HAES (200/ 0.5) + 7,2% NaCl → 250 mL bags.

Na+ 1232 mmol/ L.

Cl- 1232 mmol/ L.

pH 3.5 – 6.0.

Osmolarity: 2464 mOsm/ L.

COP 36 mm Hg.

Dosage: 4 mL/ KG (approx. 250 mL).

Infusion volume: 2 – 5 minutes.

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.

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.

Crystalloids

…

mEq/ L

Type of solution Na+ K+ Cl- Base Ca2+ Mg2+ pH kcal/ l Osmolarity

ECF (plasma) 138 5 108 27 5 3 7.4 12 Isotonic

5% glucose - - - - - - 4.5 200 Hypotonic

Jonosteril Basic 49.1 24.9 49.1 10 - 2.5 4.5-5.5 200 Hypertonic

10% glucose - - - - - - 4.5 400 Hypertonic

0.9% NaCl 154 - 154 - - - 6.0 - Isotonic

Lactated Ringer’s solution

130 4 109 28 3 - 6.5 - Isotonic

Ringer’s solution in 5% glucose

130 4 109 28 3 - 200 Hypertonic

PWE 140 4 106 45 2.5 1 4.5-7.5 Isotonic

Sterofundin 140 4 106 45 2.5 1 - Isotonic

Colloids

…

Plasma Hemohes – 6%

Voluven(Fresenius-Kabi)

Tetraspan(BBraun)

Volulyte(Fresenius-Kabi)

Hextend(Hospira) – pH: 5.9

Na+ (mmol/ L) 142 154 154 140 137 143

K+ (mmol/ L) 4.5 - - 4 4 3

Ca2+ (mmol/ L) 2.5 - - 2.5 - 5

Mg2+ (mmol/ L) 0.85 - - 1 1.5 0.9

Cl- (mmol/ L) 103 154 154 118 110 124

HCO3-(mmol/ L) 24 - - - - -

Lactate (mmol/ L) 1.5 - - - - 28

Acetate (mmol/ L) - - - 24 34 -

Malate (mmol/ L) - - - 5 - -

Osmolarity (mOsm/ L)

295 310 308 296 286.5 307

Colloid (g/ L) Protein 30-52 Starch 60 Starch 60 Starch 60 Starch 60

Crystalloids vs. colloids volume effect

…

Transfused volume[mL]

Type of infusion fluid Increase in plasma volume

[mL]

1000 5% glucose 100

1000 Lactated Ringer’s solution

250

250 7,5% NaCl 1000

500 5% Albumins 375

100 25% Albumins 450

500 Volulyte 500

Time to start fluid therapy


Pre-hospital.

Hospital emergency ward.

During emergency operations.

In ICU.

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: 265-270.2. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.

Stop the bleeding – great ‘five’ of hemorrhages:

External:

Clinical examination.

BP monitoring.

Chest:

Clinical examination and chest X-ray.

Pulmonary drainage.

Abdomen:


DPO, FAST, CT, laparoscopy, laparotomy.

Pelvis:


X-ray, CT, angiography.

Long bones.

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).

Changes Quick response Temporary response Lack of reaction

Vital functions Return to correct values Temporary improvement after which ↓BP and ↑HR

Incorrect values maintained

Estimated blood loss 10-20% 20-40% >40%

Necessity to infuse larger volume of crystalloids

Hardly possible Highly probable Highly probable

Necessity to transfuse blood Hardly possible Likely Necessary

Necessity to transfuse blood components

Hardly possible Highly possible Necessary transfusion in emergency mode

Necessity for the surgical intervention

Possible Probable Necessary

Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA. 2007.

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.

Parameter Early purpose Late purpose

SAP 90 mm Hg > 100 mm Hg

HR < 120/ min. < 100/ min.

Hct > 25% > 20%

Lactates Values lower than those after the first examination

Normal

CO Dependant upon arterial blood pressure Possibly high

RKZ No respiratory acidosis.Permitted metabolic acidosis

Normal

Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA. 2007.

Platelet count:

<50 000 2 pts.

50 – 100 000 1 pt.

Fibrinogen:

< 1g/L 1 pt.

D-dimers:

> 4 mg/L 3 pts.

0.39-4 mg/L 2 pts.

INR:

>2,3 2 pts.

1.4-2.3 1 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: 272-285.2. 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: 1327-1330.

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).

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: 272-285.2. 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: 1327-1330.3. 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: 1401-1407.

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. http://www.annalsofintensivecare.com/content/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, HCO3-).

Mixed venous oxygen saturation (SvO2).

CO2 partial pressure in mixed venous blood.

CO2 partial pressure in tissues (StCO2).

O2 partial pressure in muscles (StO2).

Blood transfusion

Miller’s Anesthesia, 7th edition. 2010: chapter 82.A practice of anesthesia for infants and children, 4th edition: chapters8 and 10. C Cote. 2009.

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.

Loss of the circulating blood volume (EBV – estimated blood volume)

Hematocrit– 40%Hematocrit RBC (PRBC) – on average approx. 60%

Crucial transfusion parameters

Product name Dosage Transfusion result

Erythrocyte concentrate 10-15 mL/KG Hemoglobin 2-3 g/dL

Erythrocyte concentrate 1 unit Hematocrit by approx. 3%.

Thrombocyte concentrate 5-10 units Platelets 50 000 – 100 000/mm3

Fresh frozen plasma 10 – 15 mL/KG Coefficient 15-20%

Kryoprecipitate 1-2 units/KG Fibrinogen 60-100 mg/dL

Miller’s Anesthesia, 7th edition. 2010: chapter 82.A practice of anesthesia for infants and children, 4th edition: chapters 8 and 10. C Cote. 2009.

End of fluid resuscitationEffective oxygen therapy resulting in the increase of SpO2>97%.

Mechanical intubation and ventilation:

Protection of lower airways:

Resolving of oxygenation abnormalities (FiO2<60% with SpO2>97%).

Resolving of ventilation impairments (ETCO2<60 mm Hg).

Replenishment of circulating blood volume (colloids, crystalloids, blood products):

CVP approx. 20 cm H2O.

Hgb: 10-12 g/dL.

Positive result of implemented therapy (including catecholamines) resulting in:

HR within: 50-120/min.

MAP within: 70-110 mm Hg.

Increase in the value of ScvO2>65%.

Decrease in lactates concentration <2 mmol/L.

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