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November2011webinar
1. Missouri EMS
Central Region
November 2011 Webinar
Contemporary Fluid Resuscitation
Jeffrey Coughenour, MD, FACS
Assistant Professor of Surgery
Medical Director, Missouri EMS Central Region
2. Purpose
• Monthly educational opportunity for
providers within the Central Region
• Focus
– Performance improvement, actual case review
– Literature review
– Discuss practice management guidelines
3.
4. Objectives
• Introduce contemporary trauma resuscitation
and review the supporting evidence
– Damage-control or hemostatic resuscitation
– Massive transfusion
– Hypertonic saline
– Other adjuncts for coagulopathy
5.
6. Origins
• Walter B. Cannon
• Fight or Flight
• Traumatic Shock, 1923
• CNS-mediated “toxic factor”
released from tissue
“…if the pressure is raised before the surgeon
is ready to check the bleeding that may take
place, blood that is sorely needed may be lost”
7. Shock
• Combination of classic shock states
– Loss of circulating blood (hemorrhagic)
– Myocardial depression (cardiogenic)
– Hypoperfusion or reperfusion injury (neurogenic)
End result—decreased oxygen delivery and
cellular dysfunction
8. Shock
• Compensated shock
– Increase in HR, vasoconstriction of non-essential
ischemic-tolerant vascular beds
• Decompensated shock
– Lack of adequate oxygen delivery builds up
“oxygen debt”, leads to cellular dysfunction and
damage, reperfusion injury, reversible
10. Dogma
• LR or NS then PRBC’s
– LR
• Diarrhea fluid from 1880, acidotic, no clotting factors, 200 mL
intravascular at 60 min, proinflammatory
– PRBCs
• Each unit increases MOF, old blood = high K+, acidotic, no clotting factors,
immunosuppressive
• Standard resuscitation approach was to
escalate use of fluids that may worsen
abnormal physiology
– 2L LR (3:1), then PRBC (10 units), then FFP (2 units)
11.
12.
13.
14. Pre-Hospital IV Fluid Administration is
Associated with Decreased Survival in Severely
Injured Trauma Patients
• Abstract, EAST 2009, Haut ER et al
• NTDB analysis, mortality as primary outcome analysis
• Subgroup analysis: Mechanism, ISS, hypotension, coma, need
for immediate surgery
• 776,734 patient data sets evaluated
– Unadjusted mortality higher 4.8 vs. 4.5% (p<0.001)
– Odds Ratio of death for IV fluid group—1.3
– Subset analysis consistent in all groups
– Association greatest in penetrating mechanism, hypotension, need
for immediate surgery
16. Prospective evaluation of preoperative fluid
resuscitation in hypotensive patients with penetrating
truncal injury: a preliminary report
Martin, Bickell, Pepe, Burch, Mattox
J Trauma 1992 Sep;33(3):354-61; discussion 361-2
• Randomization of immediate vs. delayed fluid resuscitation is
penetrating truncal injury with hypotension (< 90 mmHg)
• Immediate n=96, 56% survival to discharge
• Delayed n=81, 69% survival to discharge
• Survival advantage not statistically significant
• All other endpoints, little difference
17. Immediate versus delayed fluid resuscitation for
hypotensive patients with penetrating torso injuries
Bickell, Wall, Pepe, Martin, Allen, Mattox
N Engl J Med 1994 Oct 27;331(17):1105-9
• 598 adults randomized to immediate or delayed resuscitation
• Immediate group
– 62% survival, 30% one or more complications
• Delayed group
– 70% survival, 23% complications
• Survival p-value=0.04
• Complications: ARDS, sepsis, ARF, coagulopathy, wound
infection, pneumonia
18. Fundamental Change
• Delay in hemorrhage control—early
preventable deaths
• Large-volume crystalloid followed by
transfusion worsens reperfusion injury and
systemic inflammation—late preventable
deaths
• New methods of resuscitation and monitoring
required to prevent late trauma deaths
19.
20.
21.
22.
23. Select Population
• About 10% of injured will be hypotensive
• Of those, 3-5% due to blood loss
• Early identification of
– Abnormal physiology
– Injury parameters
• Pre-determined resuscitation strategy
24. Pattern Recognition
• Exam findings
– Decreased mental status from injury or shock
– Suspected TBI
– Clinical coagulopathy
• Laboratory values
– INR > 1.5
– Base deficit > 6
– Hemoglobin < 11
– Hypothermia (<96) or hypotension (SBP <90)
25. Pattern Recognition
• Trunk, axillary, groin, or neck wounds not
controlled by local wound care
– Direct pressure
– Tourniquet
– Hemostatic dressings
• Proximal amputation or mangled extremity
• Hemoperitoneum with shock
• Massive hemothorax
– >2000 mL initially or >200 mL per hour for 4 hours
26. Hemostatic Resuscitation
• Crystalloid to maintain radial pulse, alertness
• PRBC:FFP 3:2
• PRBC:Platelets 5:1
• Adjuncts for coagulopathy
• With cessation of hemorrhage and
normalization of physiology, minimal
crystalloid
29. Hypertonic Resuscitation of Hypovolemic Shock after
Blunt Trauma: A Randomized
Controlled Trial
Bulger EM, Jurkovich GJ, Nathens AB
Arch Surg 2008 Feb;43(2):139-48
• 250 mL of 7.5% hypertonic saline and 6% dextran (HSD) vs. LR
• 209 patients enrolled, stopped (futility) after second data
analysis
• No significant difference in ARDS-free survival
• Benefit in subset requiring >10 unit transfusion in first 24
hours
30. Prehospital resuscitation with hypertonic saline-
dextran modulates inflammatory, coagulation and
endothelial activation marker profiles in severe
traumatic brain injured patients
Rhind SD, Baker AJ, Morrison LJ, et al
J Neuroinflamm 2010 Jan 18;7:5
• Impact of prehospital resuscitation on selected cellular and
soluble inflammatory/coagulation markers
• Flow cytometry was used to analyze leukocyte cell-surface
adhesion (CD62L, CD11b) and degranulation (CD63, CD66b)
molecules
• HSD attenuated the upregulation of leukocyte/endothelial
cell proinflammatory/prothrombotic mediators
32. Massive Transfusion
• MOF lower, 9 vs 20%, p < 0.01
• 30 day survival higher 57 vs 38%, p < 0.01
• Benefit = earlier product administration
JTrauma 2009
33.
34.
35. More than 20 papers involving > 2,000 patients
In severely injured patients, early product administration
resulted in less product use and increased survival
36. Fresh Frozen Plasma Is Independently Associated With
a Higher Risk of Multiple Organ Failure and ARDS
The Inflammation and the Host Response to Injury Investigators
J Trauma 2009 Aug 67(2):221-230
• Investigate effect of plasma rich components of resuscitation
after blunt trauma
• N= 1,175 (65% FFP, 41% platelets, 28% cryo)
• With each unit of FFP, odds ratio 2.1 and 2.5 for MOF and
ARDS
37. An FFP:PRBC Transfusion Ratio >/=1:1.5 is Associated
With a Lower Risk of Mortality after Massive
Transfusion
The Inflammation and the Host Response to Injury Investigators
J Trauma 2008 Nov;65(5):986-93
• In civilian blunt trauma patients requiring ≥ 8 units
PRBCs in the first 12 hours…
– 52% mortality reduction
– No effect on MOF or nosocomial infections
– Two-fold increase in ARDS
38.
39. Lyophilized Plasma for Resuscitation in a Swine Model
of Severe Injury
Nicholas Spoerke, MD; Karen Zink, MD; S. David Cho, MD; Jerome Differding,
MPH; Patrick Muller, BS; Ayhan Karahan, MD; Jill Sondeen, PhD; John B.
Holcomb, MD; Martin Schreiber, MD
Arch Surg 2009;144(9):829-834
• LP clotting factor activity decreased average 14%
• Survival, HR, blood loss, lactate, coagulation profiles similar
between PRBC:FFP and PRBC:LP groups
• Decreased IL-6 production with LP
However, not likely available for several years…
42. Summary Points
• Surgical hemorrhage control is paramount!
• Limitation of the amount of crystalloid
improves outcomes
• Early blood products in pre-determined
amounts are effective
• rFVIIa, PCC, and tranexamic acid are likely
useful adjuncts to hemostatic resuscitation
43. Summary Points
www.pubmed.com
Search hypotensive, hemostatic, or damage-
control resuscitation
