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  1. Missouri EMS Central RegionNovember 2011 WebinarContemporary Fluid ResuscitationJeffrey Coughenour, MD, FACSAssistant Professor of SurgeryMedical 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. Objectives • Introduce contemporary trauma resuscitation and review the supporting evidence • Damage-control or hemostatic resuscitation • Massive transfusion • Hypertonic saline • Other adjuncts for coagulopathy

  4. 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”

  5. 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

  6. 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

  7. Shock

  8. 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)

  9. 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

  10. Damage Control or Hemostatic Resuscitation

  11. Prospective evaluation of preoperative fluid resuscitation in hypotensive patients with penetrating truncal injury: a preliminary reportMartin, 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

  12. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuriesBickell, 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

  13. Fundamental Change • Delay in hemorrhage control—early preventable deaths • Large-volume crystalloid followed by transfusion worsensreperfusion injury and systemic inflammation—late preventable deaths • New methods of resuscitation and monitoring required to prevent late trauma deaths

  14. 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

  15. 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)

  16. 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

  17. 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

  18. Hypertonic Saline

  19. 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

  20. Hypertonic Resuscitation of Hypovolemic Shock after Blunt Trauma: A Randomized Controlled Trial Bulger EM, Jurkovich GJ, Nathens ABArch 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

  21. Prehospital resuscitation with hypertonic saline-dextran modulates inflammatory, coagulation and endothelial activation marker profiles in severe traumatic brain injured patientsRhind 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

  22. Blood and Blood Component Therapy

  23. 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

  24. More than 20 papers involving > 2,000 patients In severely injured patients, early product administration resulted in less product use and increased survival

  25. Fresh Frozen Plasma Is Independently Associated With a Higher Risk of Multiple Organ Failure and ARDSThe 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

  26. 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 InvestigatorsJ 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

  27. Lyophilized Plasma for Resuscitation in a Swine Model of Severe InjuryNicholas 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…

  28. 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

  29. 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

  30. Summary Points www.pubmed.com Search hypotensive, hemostatic, or damage-control resuscitation

  31. December 2011 Webinar The Surgical Airway

  32. Questions ? www.muhealth.org/acutecaresurgery