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Fluids and Blood in Trauma

Fluids and Blood in Trauma. Charles E. Smith, MD Professor of Anesthesia MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio. Objectives. Overview of trauma Dx + Tx of shock Hypotensive resuscitation Crystalloid + blood products Intraop bleeding Cell salvage

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Fluids and Blood in Trauma

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  1. Fluids and Blood in Trauma Charles E. Smith, MD Professor of Anesthesia MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio

  2. Objectives • Overview of trauma • Dx + Tx of shock • Hypotensive resuscitation • Crystalloid + blood products • Intraop bleeding • Cell salvage • O2 carrying solutions • rFVIIa

  3. “Drugs, ETOH, + stupidity have given me a steady paycheck for 30 yrs” Pat Dixon MHMC OR nurse

  4. Trauma Costs • Leading cause of death, ages 1 - 44 yrs • 60 million injuries annually in USA • 30 million require medical care • 3.6 million require hospitalization • 9 million are disabling • 300 k = permanent; 8.7 million= temporary • Costs are staggering: > $100 billion annually, or 40% of health care $ ATLS Provider Manual

  5. Goals of Fluid & Blood Therapy • Restore DO2, treat injuries, maintain CPP • Prevent progression of shock • Repay cellular O2 ‘debt’ • Restore coagulation • Endpoints: normalization of multiple variables- pH, lactate, BE, urine, BP, HR, SPV, SV, pt/ptt, SvO2, CI, DO2, VO2

  6. Oxygen Delivery: DO2 • DO2 = (CaO2 x CO x 10) + (PaO2 x 0.003) • CaO2 = Hg x 1.39 x % sat • CaO2 ~ 1/2 Hct, assume CO 5 L/min, 100% sat • Hct 40 CaO2 20 CO 5 DO2 1000 • Hct 30 CaO2 15 CO 5 DO2 750 • Hct 20 CaO2 10 CO 5 DO2 500 • Hct 10 CaO2 5 CO 5 DO2 250

  7. Oxygen Debt • 1. Full recovery possible • 2. Delayed repayment of O2 debt • 3. Excessive O2 deficit w lethal cell injury • Ref: Siegel JH. Trauma: Emergency Surgery and Critical Care

  8. Estimating Oxygen Debt • Base deficit • Lactate • pH • Mixed venous O2

  9. Arterial Pulse Waveform Analysis • SPV= difference between maximal + minimal values of systolic BP during PPV •  down: normally ~ 5 mm Hg due to  venous return • SPV > 15 mm Hg, or  down > 15 mm Hg: • highly predictive of hypovolemia • LidCO/ PulseCO monitor: SPV, SV, SVV Jonas MM. Curr Opin Crit Care 2002;8:257-61

  10. Hemorrhagic Shock • Class I: < 750 ml, < 15% blood volume: • crystalloid • Class II: 750-1500 ml, 15-30% blood volume • crystalloid • Class III: 1500-2000, 30-40% blood vol • crystalloid, red cells • Class IV: > 2000, > 40% blood vol • crystalloid, red cells ITACCS 2003 Monograph on Massive Transfusion. www.itaccs.com/programs/Trans.pdf

  11. Hypotensive Resuscitation • Attempts to normalize BP with fluids & blood during uncontrolled hemorrhage: • disrupts clot, ­ risk bleeding + mortality • Animal model of uncontrolled hemorrhage: • gp 1- no surgery, no fluid: 100% mortality @ 150 min • gp 2- no fluid, surgery+fluid: 50% @ 90 m, 90% @ 3 d • gp 3- hypo resusc, MAP 40, surgery+fluid: no initial deaths, 40% @ 3 d • gp 4- resusc to MAP 80, surgery+fluid: 80% @ 90 min, ­ blood loss, all died J Am Coll Surg 1995;180:49

  12. Hypotensive Resuscitation, contd • Randomized trial, penetrating torso trauma, urban center: immediate v. delayed fluids • ­ mortality • ­ LOS • ­ complications in immediate gp • Conclusions: • Delayed fluid resuscitation acceptable if rapid dx + tx of injury Bickell et al: NEJM 1994;331:1005

  13. Dutton et al: J Trauma 2002;52:1141 • RCT, trauma pts w SBP < 90; excluded head injury: • Gp 1- fluid resusc to SBP 100 • Gp 2- fluid resusc to SBP 70 • No difference in survival: 93%, although  ISS in gp 2 [23.9 v 19.5] • Duration of bleeding similar between gps: ~ 3 h

  14. Crystalloids and Colloids • LR: slightly hypotonic 273 mOsm/L, contains Ca [do not mix with blood] • 0.9% saline: isotonic, large volumes may cause hyperchloremic metabolic acidosis • D5W: hypotonic, hyperglycemia worsens cerebral ischemia • Hetastarch: Hespan > 20 ml/kg may cause coagulopathy; Hextend better choice Boldt J: Can J Anesth 2004;51:500-13. Review

  15. Hypertonic Fluids • Rapid volume expansion:­ BP + CO • ¯ tissue edema, ICP, brain water • Improved neuro function, CPP, + survival after TBI • Resuscitation fluid of choice for prehospital TBI [Europe]

  16. SAFE Study: NEJM 2004;350:2247 • Multicenter trial: 4% albumin vs. 0.9% saline in hypovolemic ICU pts • RBCT, Australia +NZ, n=6997 • Excluded cardiac surgery, liver transplants +burns • No difference in mortality (21%), ICU (6 d) or hospital (15 d) LOS, vent days (4.5 d), new MOF • Albumin gp reqd less volume overall • Sepsis:  mortality w saline, P=0.09 • TBI:  mortality w albumin , P=0.009

  17. Indications for Transfusion • Acute blood loss + Hct < 25%: frequently • Hct < 20% or Hg < 6 g/dl: almost always • Coagulopathy: factors, platelets • Clinical judgement: CV status, age, pH, BE, additional blood loss, cardiac output, SvO2, tissue oxygenation • Use of single trigger not recommended www.asahq.org/publicationsAndServices/blood_component.html

  18. Anemia and Death • Critical DO2- point at which VO2 becomes dependent on DO2 • Elderly Jehovah’s Witness, 4500 mL blood loss, Hct  9 • Critical DO2 was 184 mL/m2/minor 5 mL/kg/min • ~ 350 mL/min/ 70 kg

  19. Anemia + Myocardial Ischemia • 52 y.o. male, high speed MCA, T10 fx, hemothorax, rib fx, pleural effusions, femur fx, widened mediastinum but negative CT • No head injury, Jehovah’s Witness • Day 1: Hct 20%, Day 2: Hct 13% • Erythropoietin, folic acid, B12, Fe: Hct  20 by day 10

  20. Anemia + Myocardial Ischemia • GA with thio, fent, vec, volatile • EBL 250 ml • Postop: • HR 136 • BP 80/50 • Hg 4.8 • Rx: phenylephrine, esmolol, neostig 6 mm ST  lead II

  21. Hebert et al: N Engl J Med 1999;340:409 • Multicenter, prospective, randomized trial of restrictive v. liberal RBC transfusion • Population: Canadian ICUs, n=4470 • 1o Diagnosis: trauma-20%, respiratory-30%, CVS-20%, GI-15%, CNS or Sepsis-5% • Restrictive: Hg 7-9, Liberal: Hg 10-12 • Conclusions: restrictive at least as effective, + possibly superior to liberal. • Exception: acute MI, unstable angina

  22. Complications of Transfusion • Impaired O2 release from Hg • Immunosuppression + infection • leuko reduced at MHMC since 8/15/01 • Coagulopathy • Hypothermia •  Ca,  K,  pH • Transfusion-related acute lung injury • Hemolytic transfusion reaction

  23. Changes in O2 Transport • P50: PO2 at which Hg is 1/2 saturated with O2 at 37 C, pH 7.40 • After 15 days storage: •  2,3 DPG •  deformability + access to capillaries • Implications: tissue hypoxia + ischemia Fitzgerald et al: CCM 1997;25:726. London, Ontario. Marik: JAMA 1993;269:3024

  24. Aged Blood • > 14 d:  proinflammatory mediators in non-leuko reduced blood • > 15 d: O2 uptake not improved acutely despite  Hg (septic ICU patients) • > 21 d:  MOF after trauma [Zallen: Am J Surg 1999;178:570] • > 28 d:  pneumonia after cardiac surgery [odds ratio 2.7] [Leal-Noval: Anesthesiology 2003;98:807] • > 28 d: VO2 not  in septic animals w supply dependent anemia [Fitzgerald: CCM 1997;25:726]

  25. Red Cell Transfusions @ MHMC N=385 trauma pts requiring surgery w/in 24 h admission, 2003-4

  26. Age of Red Cells @ MHMC N=385 trauma pts requiring surgery w/in 24 h admission, 2003-4

  27. Causes of Intraoperative Bleeding • Surgical • Hypothermia • Hemodilution w crystalloids + colloids •  coag factors, platelets + RBCs • Consumption of coag factors + platelets at site of injury • Colloids (e.g., Hespan) + hemostasis defect • DIC: • tissue trauma, TBI, shock • Other: • Preop defect, coumadin, antiplatelet meds, fibrinolysis

  28. Incidence of Hypothermia in Trauma @ MHMC N=385 trauma pts requiring surgery w/in 24 h admission, 2003-4

  29. Level 1 System H-1000 • Aluminum heat exchanger w counter current 42 oC circulating water bath • Two pressures chambers for rapid infusion • H-1200 has automatic air detection

  30. FMS 2000 Rapid Infusor • Integrated volumetric infusion pump • Magnetic induction heater • Ultrasonic air detection + line pressure sensor coupled to automatic shut off

  31. Forced-Air Warming • Efficacy + safety proven • ­ temp 1-2 oC/h • Inexpensive + non-invasive • Maintains thermoneutral environment • ¯ efficacy • vasoconstriction • insufficient surface area covered Sessler DI: Anesthesiol Clin North Am 1994;12:425

  32. Coagulation Factors •  Fibrinogen, F V + F VIII •  PT, aPTT • 1.5 to 1.8 x N • POC testing • Coagulopathy corrected with FFP, 10-15 ml/kg [Not Platelets] Murray et al: Anesthesiology 1988;69:839

  33. Platelet Works Uses standard hematology cell counting procedure. Example: baseline count = 211,000; ADP (agonist) count = 8,000; Function = (211-8)/211 x 100 = 96%

  34. Contribution of RBCs to Hemostasis • RBCs modulate biochemical + functional responsiveness of platelets • RBCs optimizes interaction of platelets w injured endothelium • RBCs  bleeding time in anemic patients w thrombocytopenia • Hct 30-35% may be necessary to sustain hemostasis in bleeding pts during massive trx Hardy JF et al: Can J Anesth 2004;51:293-310. Groupe d'Interet en Hemostase Perioperatoire

  35. Emergency Transfusion • O neg pRBC • no antigens, universal donor • contain small amt plasma w anti-A and anti-B ab • If > 2 units O neg pRBC: • crossmatch or continue with O neg • Type specific uncrossmatched • Risk of hemolytic trx rx ~ 1:1000

  36. Hemolytic Transfusion Reaction • ABO incompatibility: recipient antibody coats + destroys donor cells • Accounted for 182 deaths: more than 1/2 MD/nurse error; mortality 20-60% • Look for hemoglobinurina, bleeding diathesis, hypotension • Verify + identify each donor unit

  37. Cell-Salvage • Transfuse directly after collection or “wash” • Salvage rate: up to 50% • Savings: ~ 1-2 units allogeneic blood • Processing eliminates most leukocytes, platelets, activated factors, plasma Hg, cytokines, cell fragments, other debris • Hct of processed blood: 50-60%,  2-3 DPG v. allogeneic

  38. Evaluation of Cell Salvage @ MHMC • Retrospective review of 50 patients, Jan 1-June 17, 2003 w Fresinius CATS • Elective surgery: 74%; emerg: 26% • M/F: 60%/40% • Average EBL: 2.7 +4.2 L • Average volume returned: 2 units [0.6 + 0.9 L], or 22% of overall blood loss MHMC Research Exposition, 2003

  39. Cell Salvage @ MHMC: Results

  40. Cell Salvage • Disadvantages: • requires dedicated technical support • risk of air embolism w infusion under pressure • risk of suctioning thrombogenic material: Avitene, QuickClot, Gelfoam/thrombin, Costasis, • leukocyte activation + fat particles: use filter- e.g., Pall Leukoguard • controversial: infected wounds, tumor cells, amniotic fluid, urine • Appropriate for trauma, vascular, cardiac, ortho, + other major blood loss surgeries

  41. PolyHeme® • “Poly SFH-P Injection” • Supports life without donated blood • Immediately available • Universally compatible •  risk of disease transmission • Allows rapid, massive infusion • Shelf-life more than 1 year www.northfieldlabs.com/polyheme.htm

  42. PolyHeme Study, Northfield Phase III study to assess the survival benefit of PolyHeme® when given to severely injured and bleeding patients in hemorrhagic shock, starting at the scene of injury + continuing 12 hr postinjury in the hospital. Multicenter-12 hospitals. http://clinicaltrials.gov/show/NCT00076648

  43. Assessment of Eligibility • Inclusion criteria: • Adults w blunt or penetrating trauma • Apparent blood loss due to injury • Shock w SBP  90 mmHg at the scene of injury • Exclusion criteria: • GCS  5 or other evidence of severe head injury (e.g., blown pupil or posturing) • Asystolic or requires CPR prior to the start of infusion • Known objection to blood products http://clinicaltrials.gov/show/NCT00076648

  44. rFVIIa • Created to treat subgroup of hemophilia patients who developed antibodies, or inhibitors, to FVIII + IX • Multiple reports of ‘off-label’ use for rescue therapy of MVB after exsanguinating hemorrhage: trauma, major surgery, cirrhosis • Mechanism of action: • complexes w TF  activates FX to Fxa, + FIX to FIXa. • Fxa + other factors, converts prothrombin to thrombin • leads to formation of hemostatic plug by converting fibrinogen to fibrin + inducing local hemostasis. www.us.novoseven.com/

  45. rFVIIa for Acquired Coagulopathy • Prospective, non-randomized study, n=29 • Use of drug approved by senior MD •  bleeding in all cases • PT 17.5  9.3 +  INR to 0.6 • 15 long-term survivors • No thrombus formation • Deaths: irreversible shock, sepsis, or TBI Dutton + Scalea: J Trauma 2003;55:208 [Abstract]

  46. Pitfalls in Fluid + Bloods for Trauma 1. Failure to appreciate severity of associated injuries head trauma, shock, pulmonary contusion, hemothorax, SCI, tension pneumo, blunt + penetrating cardiac injury 2. Failure to appreciate amount of blood loss + prevent hypothermic coagulopathy 3. Failure to utilize damage control surgery 4. Failure to utilize point-of-care / stat lab 5. Failure to utilize cell-washing • Ongoing studies to determine role of O2 carrying solutions + rFVIIa

  47. Trauma Chain of Survival • ITACCS Website: www.itaccs.com/ • Programs and courses • Trauma Research, Trauma Prevention • Trauma Care Journal • On line CME

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