Missouri EMS Central Region

November 2011 WebinarContemporary Fluid Resuscitation

Jeffrey Coughenour, MD, FACS

Assistant Professor of SurgeryMedical Director, Missouri EMS Central Region

Purpose

• Monthly educational opportunity for providers within the Central Region

• Focus– Performance improvement, actual case review– Literature review– Discuss practice management guidelines

Objectives

• Introduce contemporary trauma resuscitation and review the supporting evidence– Damage-control or hemostatic resuscitation– Massive transfusion– Hypertonic saline– Other adjuncts for coagulopathy

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”

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

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

Shock

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)

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

Damage Control or Hemostatic Resuscitation

Prospective evaluation of preoperative fluid resuscitation in hypotensive patients with penetrating

truncal injury: a preliminary report

Martin, Bickell, Pepe, Burch, MattoxJ 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

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries

Bickell, Wall, Pepe, Martin, Allen, MattoxN 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

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

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

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)

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

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

Hypertonic Saline

Hypertonic Saline

• Hypothesized benefits– Intravascular volume expansion– Immunomodulatory– Improved microcirculatory flow– Inotrope via myocardial sodium channels

• Optimal formula ?– 3%, 7.5%, 7.5% with dextran

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

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 alJ 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

Blood and Blood Component Therapy

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

More than 20 papers involving > 2,000 patientsIn severely injured patients, early product administration

resulted in less product use and increased survival

Fresh Frozen Plasma Is Independently Associated With a Higher Risk of Multiple Organ Failure and ARDS

The Inflammation and the Host Response to Injury InvestigatorsJ 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

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

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…

Adjuncts

• Recombinant Factor VIIa– Creates thrombin burst, safe, pH > 7.2

• Prothrombin complex concentrates– Hemophilia, emergency reversal of Coumadin

• Tranexamic acid– Stops pathologic clot-breakdown (fibrinolysis)

after massive hemorrhage

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

Summary Points

www.pubmed.comSearch hypotensive, hemostatic, or damage-

control resuscitation

December 2011 Webinar

The Surgical Airway

Questions ?

www.muhealth.org/acutecaresurgery