The trauma patient in the ICU

Nils Oddvar Skaga, MD PhDDirector of trauma anaesthesia

Dept. of anaesthesiologyOslo University Hospital, Ullevål

Oslo – Norway

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Outline

• The trauma organisation at Ullevål• Activity• Thromboprophylaxis of trauma patients• Timing of orthopaedic surgery• Conclusion

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Admission year 3

ICU-overview, Ullevål

• General Intensive Care (10 beds) (CRRT)• Neuro Intensive Care (6 beds)• Pediatric Intensive Care (3 beds)• Post-operative dept. (10 to 12 beds)

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Trauma system overview

• OUH Ullevål – Level 1 Trauma referral centre

• Covering a population of 2.8 million• 5 HEMS-bases with physician• Severe injury:

– ISS > 15, approximately 35%– ISS > 15, 662 patients in 2016

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The trauma organisation

• A multidisciplinary team approach• All specialties available 24/7• Different professions• All departments have personnel dedicated to

trauma; patient care, quality assurance and research

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Department of traumatology

• Trauma surgeon on call• Organizing the trauma service• Trauma multidisciplinary handover and

ward rounds (incl. ICU)• Weekly trauma meeting• MM conference• DSTC courses

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Organization – 24/7

• Trauma team leader (surg. or orto. fellow)– Leading the trauma team– Follow up of all recently admitted traumas – All contacts concerning primary and secondary

referral of new trauma patients– Well known with emergency surgical

procedures– Formal education (ATLS, DSTC)

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Organization – 24/7

• Consultant anaesthesiologist resident on call– Always part of the trauma team (full team)– Responsible for resuscitation and anaesthesia– Well educated in pathophysiology and DCR– Directing all anaesthesia and ICU resources– Follow up of all ICU-patients– Formal education (ATLS, DSTC)– Representing continuity from ED to OR to ICU

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Trauma advisory board

• Representation:– Trauma– Anaesthesia– Intensive Care– Prehospital– Neuro– Gastro– Orto– Thorax– Maxillo-facial

– Urologic– Paediatric surg– Plastic– Vascular– ED– Radiology– Psychiatry– Rehab– Lab– Blood bank

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The trauma registry at OUH

• From 2001–2017, 24.000 patients• Annually approximately 2000 inclusions• Quality assurance• Research purposes

• OUH Trauma Registry Advisory Board

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A few ICU-related numbers…2016 (1894 trauma patients):• Length of stay ICU 6000 days• Mean LOS ICU 3.7 days• Number of ICU-patients 1633 (86.2%)

– Post Op 823 (50.4%)– Gen ICU 327 (20.0%)– Ped ICU 259 (15.9%)– Neuro ICU 205 (12.6%)– Other 38 ( 2.3%)– No ICU stay 260 (13.7%)

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Respirator & LOS, 2016

• 359 patients (of the 1633 ICU patients)• Days on ventilator 2513• Mean (d) 7• Median (d) 3

• Total Hospital LOS (d) 12183– Mean (d) 6.4

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Number of patients vs. mortality – ISS > 15

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The multidisciplinary nature of trauma care: also in the intensive care unit

• Multidisciplinary approach highly needed in the ED• The same approach is needed in the ICU• Continuity of vital importance, involvement of both

intensivists and surgeons are needed• Complex clinical situation

– Repeated surgical procedures– Risk of developing complications in need of

interventions

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Gaarder & Sunde, Editorial, Curr Opin Crit Care 2016, 22:560 – 562

Trauma multidisciplinary handover and ward rounds (incl. ICU)

• Every day at 09:00 (365 days)• Led by the trauma surgeon on call• Recent admissions referred• Trauma patients in ICU and Post-Op units

shortly discussed (multidisciplinary involvement)

• Parent department decided upon

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Thromboprophylaxis in trauma patients

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Thromboprophylaxis in trauma patients – risk and benefit

Bleeding VTE18nosk_2018

Trade-off between risks

• Patient risk:– severe bleeding– venous thromboembolism (VTE)

• Patient management àtrade-off between these risks

• VTE is a potentially life-threatening post-traumatic complication that might be avoided

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Challenges

• New concepts of trauma management aimed to reduce bleeding may increase the risk of VTE, e.g. hypotensive resuscitation, massive transfusion, fibrinogen concentrate, and tranexamic acid

• The risk of bleeding and VTE varies among patients, and in the same individual throughout the course of the disease

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Courtesy of Sigrid Beitland, OUH Ullevål

Severe trauma – challenges• Internal injuries• Multiple fractures• Soft tissue bleeding• Trauma Induced Coagulopathy• Organ complication (MOF)• Frequent surgery (repetitive)• Immobilisation• Multiple transfusions

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Incidence• The incidence of post-traumatic VTE is

approximately– Deep vein thrombosis (DVT): 5-63 %– Pulmonary embolism (PE): 2-22 %

• VTE occurrence depend on– Trauma population– Thromboprophylaxis regimen– Methods used to detect VTE

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Courtesy of Sigrid Beitland, OUH UllevålVan PY, Curr Op Crit Care 2016 Hamada SR, Ann Intensive Care 2017

Diagnosis

• Symptoms and clinical signs of VTE may be missing and/or difficult to detect

• Blood samples (for instance d-dimer) have low predictive value in this population

• Recommended diagnostic method for VTE– DVT: Doppler Ultrasound (DUS)– PE: Computer Topography (CT) angiography

nosk_2018 23Courtesy of Sigrid Beitland, OUH Ullevål

Recommendations

• Cochrane Library 20161

• The European guideline 20162

• ACCP 20123

• EAST 20024

• NICE Clinical guideline 20105

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1Kakkos, Cochrane Database of Systematic Reviews 2016, Issue 9. 2 Rossaint, Critical Care (2016) 20:1003 Guyatt, Chest 2012; 141 (2Suppl):7S-42S4 Rogers, J Trauma 2002; 53:142-1645 NICE Clinical guideline, nice.org.uk/guidance/cg92, 2010

Thromboprophylaxis – form

• LMWH vs. UFH – LMWH recommended

• “Evidence from this systematic review revealed a beneficial effect of LMWH compared with UFH when used as thromboprophylaxis in ICU patients”

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Beitland, Intensive Care Med (2015) 41:1209–1219

Thromboprophylaxis – dosage

• Once or twice daily? – No recommendation in EAST, ACCP or

European guidelines.• Currently, a randomized clinical trial (NCT

02342444) comparing Enoxaparin 30 mg x 2 with 40mg x 1 is in progress in Portland/Oregon with a goal to enrol 600 patients1

• OUH Ullevål: Dalteparin 5000 IE x 2 (weight adjusted)

nosk_2018 261 Van PY, Curr Op Crit Care 2016

Thromboprophylaxis – timing

• Initiation; as soon as considered safe• As early as possible (< 24 hours), both

mechanical and pharmacological• Anti-embolic stockings (all patients)• Not routine use of inferior vena cava filters

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Recommendation

• Prophylaxis should be initiated as soon as considered safe1,2, within 24 hours after bleeding has been controlled3

• Early prophylaxis is safe in TBI, SCI, and solid organ injury4

• Continue combined VTE prophylaxis until the patient no longer has significantly reduced mobility1

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1 NICE Clinical guideline, nice.org.uk/guidance/cg92, 20102 Guyatt, Chest 2012; 141 (2Suppl):7S-42S3 Rossaint, Critical Care (2016) 20:1004 Van PY, Curr Op Crit Care 2016

Our approach at Ullevål• Compression stockings – start early if possible• Dalteparin early (patient-specific dosing/timing)• Day of admittance

– 2500–5000 IE sc., if possible/safe (weight-adjusted)

• Later– Dalteparin 5000 IE x 2 (weight-adjusted)– If first dose delayed (surgery, EDA): increase next dose– We allow dosing some hours before, or six hrs after surgery

(depending on what kind of surgery)– in the presence of TBI (more conservative, 48h)

• Early mobilisation if possiblenosk_2018 29

Timing of orthopaedic surgery

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Timing of orthopaedic surgeryOn admission (ED)• Evaluate physiology• Fractures in pelvis and/or spine?• Long bone fractures? Ongoing bleeding?

– Peripheral circulation/vascular compromise?– Neurologic function– Open or closed fractures?

• Closed reduction and immobilisation with casting (in the ED) or external fixation (op).

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Open fractures

• Cleanse with sterile NaCl• Sterile dressing• Casting (or splint)

– Reduces pain– Less bleeding– Improved circulation in extremity

• Directly to OR (as early as possible) or ICU (via CT?)• Damage Control Orthopaedics (DCO)

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Closed fractures

• Patient from ED to ICU, what next?– DCO or Early Total Care (ETC)?

Involve:• Consultant Anaesthesiologist, Intensivist,

Consultant Orthopaedic surg., Trauma team leader• Choose DCO if:

– Severe shock documented (pre-hosp, ED, ongoing)– ISS > 40 – Thoracic trauma

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Damage control orthopaedics (DCO) or Early total care (ETC)

The six tests of convergence with ETC:• blood gases• core temperature• clotting• airway pressures/FIO2

• lactate < 2mmol/l• urine output >1ml/kg/hr

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Courtesy: Prof. Jan Erik Madsen, OUS Ullevål

ETC: If per-operative physiological derangement…

• Acidosis• Coagulopathy• Hypothermia

• Stop operating• Revert to DCO• Transfer to ICU

• Circulatory instability• Respiratory instability• Rise in ICP• Changes in pupillary

size/reaction

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It all comes down toadequate resuscitation

• In stable pts ETC is preferable, but

• create an operative plan fixing first things first,

and• be prepared to revert to DCO at any time

point

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Courtecy: Prof. Jan Erik Madsen, OUS Ullevål

Does a window of opportunity exist?

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Indicators of minimizing risk of second hit in the secondary phase

• Usually 2 – 6 days after trauma• Stabilized haemodynamics• Improved/ satisfactory oxygenation• Controlled inflammation: Falling CRP• Stabilized coagulation• Normothermia• Reduced capillary leakage• S-Lactate < 2 mmol/L• Diuresis >1ml/kg

• Platelets >100 x 109/L• ICP <20 mmHg nosk_2018 38

Courtecy: Prof. Jan Erik Madsen, OUS Ullevål

To sum up…

• Recognizing the pathophysiology is essential in treatment planning

• Fracture surgery in polytrauma demands close monitoring and continuous re-evaluation of the patient

• Avoid the deadly triad; hypothermia, coagulopathy and acidosis

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To sum up…

• ETC is the golden standard in polytrauma fracture care, but

• Patients with compromised physiology should be subjected to DCO only

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Anaesthesia for patients in hypovolaemic shock

Blood loss: Does it change my intravenous anesthetic?

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Ken Jonson et al. Trauma Anesthesia, 2008 & 2015

3-compartment model

nosk_2018 44Hill; 2004:76–80

3-compartment modell

• Propofol• Thiopental• Fentanyl• Ketamine

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Pharmacokinetics in severe shock

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Ref: Black et al ASA abstract, Anesthesiology 2006;105:A203

Propofol in hypovolemia

• Reduced volume of distribution (peak plasma propofol concentration increased x 2,5)– Normalizes following resuscitation

• Increased end-organ sensitivity (effect site concentration required for loss of response reduced x 2,7)– Only partly reversed by resuscitation

• Dose of Propofol must be reduced to 1/5

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Cardiodepression and vasodilation

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• The relevant parametres:– Flow (CO)– Pressure (MAP)– Systemic vascular resistance (SVR)

• Relationship:SVR = (MAP – CVP)/COSVR ≈ MAP/CO MAP ≈ CO x SVR

Why does the blood pressure fall?

• Vasodilation and cardiodepression• Reduced level of endogenous catecholamines

– Vasodilation• Increased intrathoracic pressure by intubation

– Reduced preload

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Conclusion

• Multidisciplinary approach at ICU• Thromboprophylaxis, early

– Compression stockings and LMWH• Timing of orthopaedic surgery

– Patient physiology• Anaesthesia in seriously injured patients

– Pharmacokinetics and pharmacodynamics of the drugs must be known