Fluid Therapy Fluid Therapy in Emergency Carein Emergency Care

Dr. Rashidi AhmadDr. Rashidi Ahmad

Medical Lecturer/emergentistMedical Lecturer/emergentist

School Of Medical SciencesSchool Of Medical Sciences

USM Health CampusUSM Health Campus

KelantanKelantan

22ndnd Regional Fluid Transfusion Workshop Regional Fluid Transfusion Workshop10 February 200710 February 2007

OutlineOutline

• IntroductionIntroduction• Volume therapy in hemorrhagic shockVolume therapy in hemorrhagic shock

• Crystalloid versus colloidCrystalloid versus colloid• Hypertonic saline/Small volume resuscitationHypertonic saline/Small volume resuscitation• Blood Blood

• Fluid therapy – when? How much?Fluid therapy – when? How much?• Fluid therapy in septic shockFluid therapy in septic shock• Endpoint of resuscitationEndpoint of resuscitation

“ “ The Neglected Disease of The Neglected Disease of

Modern Society”Modern Society” Trunkey, DDTrunkey, DD

Trauma Chain of survivalTrauma Chain of survival

Fluid therapy is a part of the factors…Fluid therapy is a part of the factors…

Polytrauma?Polytrauma?

• A syndrome of combined injuries with A syndrome of combined injuries with ISS > 17 & consequent SIRS for at least ISS > 17 & consequent SIRS for at least 1 day, leading to dysfunction, or failure, 1 day, leading to dysfunction, or failure, of remore organs & vital systems, which of remore organs & vital systems, which themselves had not directly been themselves had not directly been injured. injured.

Marius Keel et al. Pathophysiology of trauma. Injury (2005) 36, 691-71Marius Keel et al. Pathophysiology of trauma. Injury (2005) 36, 691-71

O2 flux = [O2 flux = [C.OC.O X Hb X SaO2 X k] + X Hb X SaO2 X k] +

[ [C.OC.O X PaO2 x 0.003] X PaO2 x 0.003]

Principle of fluid therapy Principle of fluid therapy in Emergency carein Emergency care

ShockShock

• The viability & normal functioning of multiple The viability & normal functioning of multiple organ systems & the whole body depends on organ systems & the whole body depends on continuos adjustment of C.O & DO2 to meet continuos adjustment of C.O & DO2 to meet VO2VO2

• C.OC.O VO2 & DO2 imbalance = cumulative VO2 & DO2 imbalance = cumulative O2 debtO2 debt

Cumulative O2 debt overwhelms the physiologic Cumulative O2 debt overwhelms the physiologic reserve of CVS & RS to compensates = SHOCKreserve of CVS & RS to compensates = SHOCK

Mohd Y Rady. Em. Med, 1996Mohd Y Rady. Em. Med, 1996

Traumatic shockTraumatic shock

• Tissue oxygenation is compromised by Tissue oxygenation is compromised by DODO22 (hemorrhage) & (hemorrhage) & VO VO22 (inflammatory response). (inflammatory response).

• Occurs in combination (bleeding, pain, tissue Occurs in combination (bleeding, pain, tissue edema, neurogenic shock @ tension edema, neurogenic shock @ tension pneumothorax).pneumothorax).

• Bleeding frequently occurs at multiple sites & is Bleeding frequently occurs at multiple sites & is self limiting.self limiting.

• Penetrating trauma, major bleeds rapidly leads to Penetrating trauma, major bleeds rapidly leads to hypovolemic cardiac arresthypovolemic cardiac arrest

Marius Keel, Omar Trentz. Pathophysiology of polytrauma. Marius Keel, Omar Trentz. Pathophysiology of polytrauma. Injury (2005) 36, 691 - 709Injury (2005) 36, 691 - 709

Pseudo-shockPseudo-shock

Fluid Balance Consequences Fluid Balance Consequences in Early Shockin Early Shock

• Mobilization of ECFMobilization of ECF

• Haemodilution of plasmaHaemodilution of plasma

– – ?Coagulation effects?Coagulation effects

– – Gradual fall in HbGradual fall in Hb

• Maintenance of vascular space at the Maintenance of vascular space at the expense of the ECFexpense of the ECF

Late shockLate shock

• • Capillary leakCapillary leak

• • Loss of plasma volumeLoss of plasma volume

• • Tissue edemaTissue edema

• • Organ edema (lung, kidney)Organ edema (lung, kidney)

• • Multiple organ failureMultiple organ failure

Phases of Resuscitation in Phases of Resuscitation in Trauma CareTrauma Care

• Pre-hospital ResuscitationPre-hospital Resuscitation• ED Resuscitation ED Resuscitation • Establishment of Definitive Care Establishment of Definitive Care • ICU on going resuscitationICU on going resuscitation

Aim of volume resuscitationAim of volume resuscitation

• • Early, complete restoration of tissueEarly, complete restoration of tissue

oxygenationoxygenation

• • Minimal biochemical disturbanceMinimal biochemical disturbance

• • Preservation of renal functionPreservation of renal function

• • Avoidance of transfusion complicationsAvoidance of transfusion complications

Goals of Fluid therapy in Goals of Fluid therapy in hemorrhagic shockhemorrhagic shock

• First Priority: First Priority: Restore volumeRestore volume

• Second Priority: Second Priority: Restore blood - Restore blood - oxygen carrying capacityoxygen carrying capacity

• Third Priority: Third Priority: Normalize coagulation Normalize coagulation statusstatus

Fluid of choicesFluid of choices

• Well-balanced resuscitation fluid Well-balanced resuscitation fluid resembling ECFresembling ECF

• Rapid volume expansion of IVSRapid volume expansion of IVS

• Sustained expansionSustained expansion

• No sugarNo sugar

Options for fluid resuscitationOptions for fluid resuscitation

• Crystalloid – NS, Lactated Ringers’s Crystalloid – NS, Lactated Ringers’s solution, hypertonic salinesolution, hypertonic saline

• Colloid – albumin, gelatine, dextran, Colloid – albumin, gelatine, dextran, starch (VOLUVEN)starch (VOLUVEN)

• Blood – allogenic blood, autologous Blood – allogenic blood, autologous bloodblood

• Blood substitutes – cross-linked, Blood substitutes – cross-linked, polymerize @ conjugated Hbpolymerize @ conjugated Hb

Optimal fluid resuscitationOptimal fluid resuscitation

• No ideal fluid resuscitationNo ideal fluid resuscitation• Combination therapyCombination therapy– Volume expansionVolume expansion– O2 carrying capacity of blood, without the O2 carrying capacity of blood, without the

need for cross matching @ the risk of need for cross matching @ the risk of transmissiontransmission

– Restore & maintain the normal composition & Restore & maintain the normal composition & distribution of body fluid compartmentdistribution of body fluid compartment

CrystalloidsCrystalloids

• • Ringer’s:Ringer’s:

– – Low sodium, lactate loadLow sodium, lactate load

• • Saline:Saline:

– – Hyperchloraemic acidosis, no K+Hyperchloraemic acidosis, no K+

• • Both:Both:

– – Large volume resuscitation needed (3:1)Large volume resuscitation needed (3:1)

CrystalloidCrystalloid

CrystalloidsCrystalloids

• Lower costLower cost• EC expanderEC expander• Greater urinary flowGreater urinary flow• Replaces interstitial fluidReplaces interstitial fluid• Transient haemodynamic improvement (20 – Transient haemodynamic improvement (20 –

30 min)30 min)• Peripheral oedemaPeripheral oedema• Pulm oedema (protein dilution + Pulm oedema (protein dilution + PAOP) PAOP)

ColloidsColloids

• Greater costGreater cost• IV expander, do not resuscitate ECFIV expander, do not resuscitate ECF• Smaller volume (1:1)Smaller volume (1:1)• Osmotic diuresisOsmotic diuresis• Longer duration of persistence (2 – 8 hours)Longer duration of persistence (2 – 8 hours)• Less cerebral oedemaLess cerebral oedema• CoagulopathyCoagulopathy• Pulm oedema (cap. leak state)Pulm oedema (cap. leak state) GFR (hyperoncotic kidney failure syndromeGFR (hyperoncotic kidney failure syndrome• Improved rheologyImproved rheology• • Allergic risk (gelatin > dextran > HES)Allergic risk (gelatin > dextran > HES)

Colloid Colloid (no capillary leakage)(no capillary leakage)

Colloids versus crystalloids for fluid Colloids versus crystalloids for fluid resuscitation in critically ill patients:resuscitation in critically ill patients:

• The Cochrane review: Lancet; Issue 2 The Cochrane review: Lancet; Issue 2 Oxford 2000 by Alderson P, Schierhout G, Oxford 2000 by Alderson P, Schierhout G, Roberts I, Bunn FRoberts I, Bunn F

• Conclusion: No evidence that resuscitation Conclusion: No evidence that resuscitation with colloids reduces the risk of death with colloids reduces the risk of death compared with crystalloid in patient with compared with crystalloid in patient with traumatic injurytraumatic injury

The crystalloid–colloid debate The crystalloid–colloid debate has evolved into a colloid-has evolved into a colloid-

colloid debatecolloid debate

Ideal colloidIdeal colloidNational Research Council – USA (1963)National Research Council – USA (1963)

1.1. Rapidly replaces blood volume losses.Rapidly replaces blood volume losses.

2.2. Restores the haemodynamic balance.Restores the haemodynamic balance.

3.3. Normalizes microcirculatory flow.Normalizes microcirculatory flow.

4.4. Have a sufficiently long intravascular life.Have a sufficiently long intravascular life.

5.5. Be readily metabolized, readily excreted and well Be readily metabolized, readily excreted and well tolerated.tolerated.

6.6. Be free of side effects, especially regarding Be free of side effects, especially regarding haemostasis and anaphylactoid reactionhaemostasis and anaphylactoid reaction

7.7. Be cost effective and contribute to blood savings.Be cost effective and contribute to blood savings.

GelatinsGelatins

• Short actingShort acting

• Prevent platelet aggregation induce by Prevent platelet aggregation induce by ristocetin - minimal effect on coagulationristocetin - minimal effect on coagulation

• May be diureticMay be diuretic

• Allergy riskAllergy risk

• Contain high [CaContain high [Ca2+2+) ~ facilitate clotting) ~ facilitate clotting

DextransDextrans

• Good duration of effectGood duration of effect• Good rheological effect (esp Dextran 40)Good rheological effect (esp Dextran 40)• Allergy riskAllergy risk• Significant coagulation effectSignificant coagulation effect• May interfere with cross-matchMay interfere with cross-match• Dextran 40 can cause osmotic renal damageDextran 40 can cause osmotic renal damage

AlbuminAlbumin

• ExpensiveExpensive• • No evidence of benefitNo evidence of benefit• • Some evidence of harmSome evidence of harm• • ANZICS SAFE study:ANZICS SAFE study:– – 7000 patients randomized to Alb or NS7000 patients randomized to Alb or NS– – Increased mortality with albumin Increased mortality with albumin

(p<0.05) in trauma (more intracerebral (p<0.05) in trauma (more intracerebral bleeding)bleeding)

StarchesStarches

• Good duration of effectGood duration of effect

• High molecular weight starches impair High molecular weight starches impair coagulationcoagulation

• Medium molecular weight HES has Medium molecular weight HES has minimal effectminimal effect

• Possible endothelial benefitPossible endothelial benefit

Hetastarch Hetastarch (hydroxyethyl starch)(hydroxyethyl starch)

• Derived from corn starchDerived from corn starch• Modified natural polymers of amylopectin Modified natural polymers of amylopectin

which breaks down by amylasewhich breaks down by amylase IV persistence due to substitution of IV persistence due to substitution of

hydroxyethyl group with D – glucose & more hydroxyethyl group with D – glucose & more of glucose molecules hydroxylated at the C2 of glucose molecules hydroxylated at the C2 position versus the C6 position, position versus the C6 position,

Hetastarch evolutionary Hetastarch evolutionary conceptconcept

• A high degree of substitution (> 0.6), a high A high degree of substitution (> 0.6), a high C2:C6 ratio (> 8), and a high initial MW (> C2:C6 ratio (> 8), and a high initial MW (> 450 kDa) will maximize the intravascular half-450 kDa) will maximize the intravascular half-life.life.

• Polymers with a MW < 50 kDa are eliminated Polymers with a MW < 50 kDa are eliminated rapidly by glomerular filtration and larger rapidly by glomerular filtration and larger polymers are hydrolysed by amylase into polymers are hydrolysed by amylase into smaller molecules.smaller molecules.

HAES classificationHAES classification

Types of HESTypes of HES

• 11stst HES – marketed in US & Germany, HES – marketed in US & Germany, 450kDa, a/w coagulopathy, withdrawn450kDa, a/w coagulopathy, withdrawn

• Elohes 6% - (200/0.62)Elohes 6% - (200/0.62)

• Lomol 10% - (250/0.45)Lomol 10% - (250/0.45)

• Haes – Steril 6% - (200/0.5)Haes – Steril 6% - (200/0.5)

• Voluven 6% - (130/0.4)Voluven 6% - (130/0.4)

Advantages of HESAdvantages of HES

• Encourages the restoration of cell mediated Encourages the restoration of cell mediated function and macrophage function after function and macrophage function after hemorrhagic shockhemorrhagic shock

Schmand JF et al. Criti Care Med 1995;23:806–14.Schmand JF et al. Criti Care Med 1995;23:806–14.

• 10% HES (200:0.5) resulted in significantly 10% HES (200:0.5) resulted in significantly better systemic haemodynamics and better systemic haemodynamics and splanchnic perfusion than volume splanchnic perfusion than volume replacement with 20% human albuminreplacement with 20% human albumin

Boldt J et al. Anesth Analg 1996;83:254–61.Boldt J et al. Anesth Analg 1996;83:254–61.

HES & allergic reactionsHES & allergic reactions

Laxenaire MC et al. Anaphylactoid reactions to colloid plasma Laxenaire MC et al. Anaphylactoid reactions to colloid plasma substitutes: incidence risk factors mechanisms. Annales Francais substitutes: incidence risk factors mechanisms. Annales Francais

d’Anesthesie et Reanimation 1994;13:301–10 A French multicenter d’Anesthesie et Reanimation 1994;13:301–10 A French multicenter prospective study.prospective study.

Disadvantages of HESDisadvantages of HES

• Repeated administration of HAES especially Repeated administration of HAES especially high in vivo MW – reduce factor VIII & VWF & high in vivo MW – reduce factor VIII & VWF & renal function (coagulopathy & anuria)renal function (coagulopathy & anuria)

• Haes – Steril solutions, medium MW were Haes – Steril solutions, medium MW were widely used for intravascular volume widely used for intravascular volume replacement in cardiac surgery.replacement in cardiac surgery.

• Recommended max dose per day: 20 – 33 Recommended max dose per day: 20 – 33 ml/kg.ml/kg.

VoluvenVoluven

• HES 130/0.4 was developed with the aim of HES 130/0.4 was developed with the aim of improving the pharmacokinetic & Mw improving the pharmacokinetic & Mw distribution profile of HES 200/0.5distribution profile of HES 200/0.5

• Their beneficial effects appear to be related Their beneficial effects appear to be related more to their action on inflammatory more to their action on inflammatory processes than their colloid osmotic powerprocesses than their colloid osmotic power

• It has been shown in few pharmacokinetic It has been shown in few pharmacokinetic studies that voluven solutions were decreased studies that voluven solutions were decreased in plasma & tissue storage after repeated in plasma & tissue storage after repeated administration (50 – 75 ml/kg/d) & less administration (50 – 75 ml/kg/d) & less influence on coagulation.influence on coagulation.

Anest Analg 2003;96:936 – 43Anest Analg 2003;96:936 – 43Anesthesiology, V 99, No 1, Jul 2003Anesthesiology, V 99, No 1, Jul 2003

Hypertonic salineHypertonic salineStackford SR. J Trauma 1998:44:50-8Stackford SR. J Trauma 1998:44:50-8

• High osmolality (2400 mOsmol/L)High osmolality (2400 mOsmol/L)• Small Volume ResuscitationSmall Volume Resuscitation• Reduced cerebral edemaReduced cerebral edema• Reduced trauma-induced immuno-suppression• CI: dehydration, oliguric renal failure, cardiogenic CI: dehydration, oliguric renal failure, cardiogenic

shock, DKA, coagulopathies or active shock, DKA, coagulopathies or active hemorrhage hemorrhage

• Central pontine myelinosis : NO clinically Central pontine myelinosis : NO clinically significant & were not reportedsignificant & were not reported

• Practical dose: 200mls 7.5% NaCl in 10 minPractical dose: 200mls 7.5% NaCl in 10 min

Hypertonic SalineHypertonic Saline

Velasco IT et al. HyperosmoticVelasco IT et al. HyperosmoticNaCl and severe hemorrhagic shock. NaCl and severe hemorrhagic shock.

Am J Physiol 1980;239:H664-73Am J Physiol 1980;239:H664-73

• Severely hemorrhaged dogs (40 ml/kg Severely hemorrhaged dogs (40 ml/kg blood loss) re- sponded with a restored blood loss) re- sponded with a restored arterial pressure and cardiac output arterial pressure and cardiac output following IV bolus injections of 4 mL/kg following IV bolus injections of 4 mL/kg of 7.5% NaCl,of 7.5% NaCl,

• A volume equivalent to only 10% of the A volume equivalent to only 10% of the volume of shed bloodvolume of shed blood

Best evidenceBest evidence

• Wade CE et al. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies. Surgery 1997;122:609-16.

• 14 trials (1200 patients, 8 HSD, 6 HS)• Conclusion: No differences in survival

with HS, HSD, crystalloid

Best evidenceBest evidence

• Wade CE et al. Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and hypotension J. Trauma 1997;42:S61-5.

• RCT comparing HSD & HS alone, as compared to crystalloid.

• Conclusion: some benefit of HS in penetrating injuries and those with combined shock and severe head injury.

BloodBlood

• Oxygen flux: CO × O2 content : CO(SaO2 × Hb × 1.34)

• Blood transfusion is reserved for cases of significant or ongoing bleeding.

• Why? Why? - Limited blood supply- Limited blood supply- Need to be re warmed- Need to be re warmed- Disease transmission- Disease transmission- Immunosuppressive effect/ risk of infection- Immunosuppressive effect/ risk of infection- I- Independent risk factor for post-traumatic organ dysfunction.

BloodBlood

• Limit transfusionsLimit transfusions

• Transfusion threshold < 7g/dlTransfusion threshold < 7g/dl

• Maintenance level 7 – 9 g/dlMaintenance level 7 – 9 g/dl

• Older patients and those with ischemic Older patients and those with ischemic heart disease may need higher Hbheart disease may need higher Hb

Alternative choicesAlternative choices

• Autologous blood salvage techniqueAutologous blood salvage technique

• Blood substituteBlood substitute

- modified hemoglobins- modified hemoglobins

- perfluorocarbons- perfluorocarbons

Autologous blood salvage Autologous blood salvage techniquetechnique

• Example: to reinfuse blood loss secondary to a massive hemothorax.

• Tedious & technical, need experienced personal

• Risk of bacterial contamination

• Micro emboli of platelet plugs and fractured red blood cells.

Artificial hemoglobinArtificial hemoglobin

• Sloan EP et al. Diaspirin cross linked Sloan EP et al. Diaspirin cross linked hemoglobin (DCLHb) in the treatment of hemoglobin (DCLHb) in the treatment of severe traumatic hemorrhagic shock. a severe traumatic hemorrhagic shock. a randomized controlled efficacy trial. randomized controlled efficacy trial.

• JAMA 1999; 282:1857-1864JAMA 1999; 282:1857-1864

• Study terminated prematurelyStudy terminated prematurely

• Increased number of death in the Increased number of death in the experimental group.experimental group.

Hemoglobin based oxygen Hemoglobin based oxygen carrier HBOCscarrier HBOCs

• Analdo BD, Minei JP. Potential of hemoglobin Analdo BD, Minei JP. Potential of hemoglobin based oxygen carrier in trauma patients. based oxygen carrier in trauma patients.

• Curr Opin Crit Care 2001; 7: 431-436Curr Opin Crit Care 2001; 7: 431-436• Excellent overview relevant to traumaExcellent overview relevant to trauma• Problem: nitric oxide scavenging effects Problem: nitric oxide scavenging effects

leading to smooth muscle constriction and leading to smooth muscle constriction and subsequent blood pressure elevationsubsequent blood pressure elevation

HBOC- 201HBOC- 201

• McNeil JD, Smith Ld, Jenkins DH, et al.McNeil JD, Smith Ld, Jenkins DH, et al.• J Trauma 2001; 50:1063-1075J Trauma 2001; 50:1063-1075• Hypotensive resuscitation using a polymerized Hypotensive resuscitation using a polymerized

bovine hemoglobin-based oxygen carrying bovine hemoglobin-based oxygen carrying solution (HBOC- 201) leads to reversal of solution (HBOC- 201) leads to reversal of anaerobic metabolism. anaerobic metabolism.

Fluid resuscitation: WHEN & Fluid resuscitation: WHEN & HOW MUCH?HOW MUCH?

• Traditional strategy: to restore patients to a Traditional strategy: to restore patients to a normovolemic state ASAPnormovolemic state ASAP

• Based on animal studies (1950 – 60) & Vietnam Based on animal studies (1950 – 60) & Vietnam war.war.

• Recent strategy: judicious use of fluids, SVRRecent strategy: judicious use of fluids, SVR• Lack of randomized controlled studies, lack of Lack of randomized controlled studies, lack of

implementationimplementation• ? No documentation support the proposed ? No documentation support the proposed

changes actually will improve patient outcomechanges actually will improve patient outcome

Treatment with IV fluids before hemorrhage Treatment with IV fluids before hemorrhage was controlled increased the mortality rate, was controlled increased the mortality rate, especially if the BP was elevated.especially if the BP was elevated.

Kowalenko T, Stern S, Dronen S, Wang X. Improved outcome with Kowalenko T, Stern S, Dronen S, Wang X. Improved outcome with hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine model. J Trauma 1992;33:349-53. model. J Trauma 1992;33:349-53.

Stern S, Dronen S, Birrer P, Wang X. Effect of blood pressure on Stern S, Dronen S, Birrer P, Wang X. Effect of blood pressure on hemorrhage volume and survival in a near- fatal hemorrhage model hemorrhage volume and survival in a near- fatal hemorrhage model incorporating a vascular injury. Ann Emerg Med 1993;22:155-63.incorporating a vascular injury. Ann Emerg Med 1993;22:155-63.

PostulationPostulation

• Increased hydrostatic pressure driving ongoing bleeding or dislodging a clot, as well as the decrease in blood viscosity and dilution of clotting factors.

- Shoemaker WC et al. Resuscitation from severe hemorrhage. Crit Care Med 1996;24:S12-23.

• A caveat that also bears consideration when comparing such studies, is the anesthetic used, which can also significantly affect blood loss.

- Soucy DM et al. Effects of anesthesia on a model of uncontrolled hemorrhage in rats. Crit Care Med

1995;23:1528-32.

SBP thresholdSBP threshold

• Sondeen JL et al. BP at which Sondeen JL et al. BP at which rebleeding occurs after resuscitation in rebleeding occurs after resuscitation in swine with aortic injury.swine with aortic injury.

• J Trauma 2003;54:S110-7J Trauma 2003;54:S110-7

• Findings: SBP threshold = 90 mmHg, Findings: SBP threshold = 90 mmHg, independent of time from start of independent of time from start of bleeding.bleeding.

• Administering large quantities of IV fluids Administering large quantities of IV fluids without controlling the hemorrhage results in without controlling the hemorrhage results in hemodilution (hemodilution ( HCT, HCT, available Hb (and available Hb (and oxygen- carrying capacity), oxygen- carrying capacity), clotting factors & clotting factors & ECF compartmentECF compartment

• This effect is found regardless of the fluid This effect is found regardless of the fluid used (blood, LR, NS, hypertonic saline). used (blood, LR, NS, hypertonic saline).

Hahn RG. The use of volume kinetics to Hahn RG. The use of volume kinetics to optimize fluid therapy. optimize fluid therapy.

J Trauma 2003;54:S155-8J Trauma 2003;54:S155-8

The optimal volume of IV fluid administered The optimal volume of IV fluid administered is a balance between improving tissue is a balance between improving tissue oxygen delivery against increasing the oxygen delivery against increasing the

blood loss by raising SBPblood loss by raising SBP

MODSMODS CLOTSCLOTS

Delayed fluid resuscitation in penetrating trauma

• Bickell WH et al. Bickell WH et al. • New Engl J Med 1994;331:1105-9. New Engl J Med 1994;331:1105-9. • Randomized, prospective and blinded comparison Randomized, prospective and blinded comparison

of immediate versus delayed fluid resuscitation for of immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso hypotensive patients with penetrating torso injuries.injuries.

• Methods: Methods: • Patients in the immediate resuscitation group received Patients in the immediate resuscitation group received

infusion of isotonic infusion of Ringer's acetate solution infusion of isotonic infusion of Ringer's acetate solution through two large bore IV catheters inserted at the through two large bore IV catheters inserted at the scene. scene.

Delayed fluid resuscitation in Delayed fluid resuscitation in penetrating traumapenetrating trauma

• Patients in the delayed resuscitation group also Patients in the delayed resuscitation group also had two large bore IV catheters inserted at the had two large bore IV catheters inserted at the scene but these were then flushed and capped.scene but these were then flushed and capped.

• After arrival in the operating room, IV crystalloid After arrival in the operating room, IV crystalloid and packed red cells were given to all patients to and packed red cells were given to all patients to maintain SBP > 100 mm Hg, HCT > 25% and maintain SBP > 100 mm Hg, HCT > 25% and urine output > 50 ml per hour. urine output > 50 ml per hour.

• The majority of patients were in hospital within 30 The majority of patients were in hospital within 30 min of reported injury and entered the OR < 1H of min of reported injury and entered the OR < 1H of hospital time. hospital time.

Delayed fluid resuscitation in Delayed fluid resuscitation in penetrating traumapenetrating trauma

• 598 studied patients, 70 died before reaching 598 studied patients, 70 died before reaching the OR. the OR.

• Survival rate of delayed resuscitation group Survival rate of delayed resuscitation group (70%) compared with that in the immediate (70%) compared with that in the immediate resuscitation group (62%). resuscitation group (62%).

• The frequency of complications was similar in The frequency of complications was similar in the two groups. the two groups.

• Conclusion: In hypotensive patients with Conclusion: In hypotensive patients with penetrating torso trauma, delay of fluid penetrating torso trauma, delay of fluid resuscitation until operative intervention resuscitation until operative intervention improves outcome.improves outcome.

Regel et al, Acta Regel et al, Acta Anaesthesiol.Scand., 1997Anaesthesiol.Scand., 1997

• Data limited to penetrating injuriesData limited to penetrating injuries• No evidence for blunt haemorrhagic No evidence for blunt haemorrhagic

traumatrauma• Decision on field resuscitation relates Decision on field resuscitation relates

to type of trauma and likelihood of to type of trauma and likelihood of hospital transferhospital transfer

On going debate/uncertaintyOn going debate/uncertainty

• Best practice for:Best practice for:• Penetrating versus blunt traumaPenetrating versus blunt trauma• Rural versus urban settingsRural versus urban settings• Young versus older patientsYoung versus older patients• Head injured versus non head injured Head injured versus non head injured

patientspatients

• ? Malaysian Practice? Malaysian Practice

Timing of resuscitationTiming of resuscitation

• Do not delay transfer for resuscitationDo not delay transfer for resuscitation

• Priority is arrest of hemorrhagePriority is arrest of hemorrhage

• Commence aggressive resuscitation Commence aggressive resuscitation once control of bleeding is imminentonce control of bleeding is imminent

Pepe et al Emerg.Med Clin.North Am., 1998Pepe et al Emerg.Med Clin.North Am., 1998

Pre-hospital resuscitationPre-hospital resuscitationSøreide & Deakin, Injury, 2005Søreide & Deakin, Injury, 2005

• Set resuscitation targets according to type Set resuscitation targets according to type of traumaof trauma

• • Start isotonic crystalloid infusionStart isotonic crystalloid infusion– – Rapid 500ml to achieve targetsRapid 500ml to achieve targets

• • Reassess after each fluid bolusReassess after each fluid bolus• • Do not delay transportation for other than Do not delay transportation for other than

life-saving maneuverslife-saving maneuvers• • Maintain care during transportationMaintain care during transportation

Blunt TraumaBlunt TraumaSøreide & Deakin, Injury, 2005Søreide & Deakin, Injury, 2005

• • Goals:Goals:– – Perfusion of vital organs without increasingPerfusion of vital organs without increasing

bleedingbleeding

• • Minimal fluid resuscitationMinimal fluid resuscitation– – Rapid infusion of rapid 500ml of isotonic crystalloidRapid infusion of rapid 500ml of isotonic crystalloid

• • Targets:Targets:– – Restore peripheral pulsesRestore peripheral pulses

– – Keep systolic arterial pressure < 90mmHgKeep systolic arterial pressure < 90mmHg

TBITBISøreide & Deakin, Injury, 2005Søreide & Deakin, Injury, 2005

• • Goals:Goals:– – Limit bleeding riskLimit bleeding risk– – Maintain CPPMaintain CPP

• • Moderate fluid resuscitationModerate fluid resuscitation– – Rapid infusion of rapid 500ml of isotonic Rapid infusion of rapid 500ml of isotonic

crystalloidcrystalloid

• • Targets:Targets:– – Restore and maintain SBP > 110mmHgRestore and maintain SBP > 110mmHg

Penetrating injuryPenetrating injurySøreide & Deakin, Injury, 2005Søreide & Deakin, Injury, 2005

• • Goals:Goals:– – Perfusion of at least brain and heart without Perfusion of at least brain and heart without

increasing bleedingincreasing bleeding

– – Rapid transferRapid transfer

• • Minimal fluid resuscitationMinimal fluid resuscitation– – Rapid infusion of 500ml of isotonic crystalloidRapid infusion of 500ml of isotonic crystalloid

• • Targets:Targets:– – Restore basal cerebral perfusionRestore basal cerebral perfusion

– – Keep systolic arterial pressure < 80mmHgKeep systolic arterial pressure < 80mmHg

Søreide & Deakin, Injury Søreide & Deakin, Injury (2005) 36, 1001 - 1010(2005) 36, 1001 - 1010

• Fluid resuscitation & blood transfusion Fluid resuscitation & blood transfusion in the Emergency Department are still in the Emergency Department are still essential elements of the early hospital essential elements of the early hospital management of critically ill injured management of critically ill injured patientspatients

Rocha-e-Silva et al. CLINICS 60(2):159-172, 2005

• Review paper: Small volume hypertonic resuscitation of circulatory shock.

• Conclusions:• Safe, but cautious in moribund, or chronic debilitating

diseases.• First treatment for posttraumatic hypotension, particularly in

penetrating trauma head trauma.• Not a/w increased bleeding, clinically significant

hypernatremia and allergic reactions

• Commercially available in European countries. • A larger prospective, multicenter trials is required to

better define the patient population to maximally benefit from hypertonic saline

• SIRS (2 out of 4 criteria) with detection of SIRS (2 out of 4 criteria) with detection of bacterial focusbacterial focus

• ±±/elevated CRP/elevated pro-calcitonin/elevated CRP/elevated pro-calcitonin• Septic shock: sepsis-induced with hypotension Septic shock: sepsis-induced with hypotension

despite adequate fluid resuscitation along with despite adequate fluid resuscitation along with the presence of perfusion abnormalities that the presence of perfusion abnormalities that may include, but not limited to lactic acidosis, may include, but not limited to lactic acidosis, oliguria or acute alteration of mental statusoliguria or acute alteration of mental status

SepsisSepsis

Crit Care Med 1992;20:864-74Crit Care Med 1992;20:864-74

Fluids in septic shockFluids in septic shockMarx et al. Marx et al. Int Care MedInt Care Med, 2002, 2002

• • 25 fasted, ventilated pigs25 fasted, ventilated pigs• • Faecal peritonitisFaecal peritonitis• • Fluid titrated to keep CVP 12mmHgFluid titrated to keep CVP 12mmHg

– – Ringer’s solution (RS)Ringer’s solution (RS)– – Modified fluid gelatin 4% (MFG4%)Modified fluid gelatin 4% (MFG4%)– – Modified fluid gelatin 8% (MFG8%)Modified fluid gelatin 8% (MFG8%)– – Hydroxyethyl starch 200/0.5 (HES)Hydroxyethyl starch 200/0.5 (HES)

• • Haemodynamics and oxygenation measured Haemodynamics and oxygenation measured at 4 and 8 hoursat 4 and 8 hours

Marx et al. Int Care Med, 2002

Fluid requirementsFluid requirements

Cardiac outputCardiac output

Marx et al. Marx et al. Int Care MedInt Care Med, 2002, 2002

Mixed SMixed SvvOO22

Marx et al. Marx et al. Int Care MedInt Care Med, 2002, 2002

Acid baseAcid base

Marx et al. Marx et al. Int Care MedInt Care Med, 2002, 2002

Fluids in septic shockFluids in septic shockMarx et al. Marx et al. Int Care MedInt Care Med, 2002, 2002

• Conclusions:Conclusions:

• Colloids were significantly better than Colloids were significantly better than Ringer’s for resuscitation in this modelRinger’s for resuscitation in this model

• HES appeared to be slightly better than HES appeared to be slightly better than either isotonic or hypertonic gelatineither isotonic or hypertonic gelatin

SepsisSepsis

• • Goals:Goals:– – Restore tissue perfusion rapidlyRestore tissue perfusion rapidly

• • Aggressive fluid resuscitationAggressive fluid resuscitation– – Rapid infusion of 500ml of isotonic crystalloid and Rapid infusion of 500ml of isotonic crystalloid and

colloidcolloid

– – Inotropic support as requiredInotropic support as required

• • Targets:Targets:– – Maintain ScvO2 > 70%Maintain ScvO2 > 70%

– – Keep systolic arterial pressure > 65mmHgKeep systolic arterial pressure > 65mmHg

End point of resuscitationEnd point of resuscitation

• Traditional: Achieved definitive care Traditional: Achieved definitive care

• New: Correction of ONew: Correction of O22 debt as end point debt as end point

Prehospital care,Prehospital care,Arrival to EDArrival to ED

Stabilization Stabilization of vital signsof vital signs

Relieve tissue Relieve tissue hypoxiahypoxia

Admission in ICUAdmission in ICU

Phase 1Phase 1 Phase 2Phase 2 Phase 3Phase 3

End point of Resuscitation of ShockEnd point of Resuscitation of Shock

RADY ET AL • RESUSCITATION IN THE ED. AMERICAN JOURNAL OF RADY ET AL • RESUSCITATION IN THE ED. AMERICAN JOURNAL OF

EMERGENCY MEDICINE • Volume 14, Number 2 • March 1996EMERGENCY MEDICINE • Volume 14, Number 2 • March 1996. .

End point of Resuscitation of ShockEnd point of Resuscitation of Shock

End point of ResuscitationEnd point of Resuscitation

Davis , Shackford. Base deficit as a guide Davis , Shackford. Base deficit as a guide to volume resuscitation. J. trauma 1988.to volume resuscitation. J. trauma 1988.

• Mild: -2 to -5, moderate: -6 to -14, Mild: -2 to -5, moderate: -6 to -14,

severe: > -14 severe: > -14 • Worsening base deficit correlated with Worsening base deficit correlated with

ongoing blood lossongoing blood loss• normal base deficit taken as end point of normal base deficit taken as end point of

resuscitationresuscitation

• 76 patients76 patients• Lactate normalized in 24 hr: 100 % survival, Lactate normalized in 24 hr: 100 % survival, 24 – 48 hr 78 % survival, > 48 hr: 14 % survivors24 – 48 hr 78 % survival, > 48 hr: 14 % survivors• Serum lactate and time to normalization (less Serum lactate and time to normalization (less than or equal to 2 mmol/l) appears to be a than or equal to 2 mmol/l) appears to be a suitable end point for resuscitationsuitable end point for resuscitation

Abramson et al. Lactate clearance and survival Abramson et al. Lactate clearance and survival following injury. J. Trauma . 1993following injury. J. Trauma . 1993

Bishop, Shoemaker & colleagueBishop, Shoemaker & colleagueJ. Trauma 1995J. Trauma 1995

• Prospective randomized trial of survivors Prospective randomized trial of survivors values of C.I, Ovalues of C.I, O22 delivery and O delivery and O2 2

consumption as resuscitation end point in consumption as resuscitation end point in severe traumasevere trauma

• Supranormal valuesSupranormal values– Cardiac Index: CI > 4.5 L/minCardiac Index: CI > 4.5 L/min

– OO22 Delivery index: DO Delivery index: DO22 I > 600ml/min/m2 I > 600ml/min/m2

– OO22 consumption index: VO consumption index: VO22 I > 170 ml/min/m2 I > 170 ml/min/m2

Bishop, Shoemaker & colleagueBishop, Shoemaker & colleagueJ. Trauma 1995J. Trauma 1995

• 50 patients on supranormal variables cf 50 patients on supranormal variables cf 65 control patients 65 control patients • lower mortality ( 18 % Vs 37 % )lower mortality ( 18 % Vs 37 % )• fewer organ failures per patientfewer organ failures per patient

– DODO22I & VOI & VO22I are strong predictor of multiple I are strong predictor of multiple

organ failure and deathorgan failure and death– Standard hemodynamic measurement MAP, Standard hemodynamic measurement MAP,

CVP fail to differentiate between survivor and CVP fail to differentiate between survivor and non- survivors.non- survivors.

SummarySummary• Severe hemorrhagic shockSevere hemorrhagic shock

• Aggressive versus judicious fluid therapy (inconclusive)Aggressive versus judicious fluid therapy (inconclusive)• Restrictive & permissive hypotension in uncontrolled Restrictive & permissive hypotension in uncontrolled

hemorrhage (clinical evidence is still limited).hemorrhage (clinical evidence is still limited).• Minimum resuscitation, stop the bleeding (surgical Minimum resuscitation, stop the bleeding (surgical

intervention) then maximum resuscitation.intervention) then maximum resuscitation.• Future trend may be SVR with HS Future trend may be SVR with HS • Ringer’s lactate @ NS/Ringer’s lactate @ NS/±Starch±Starch is an initial fluid of is an initial fluid of

choice choice • Red blood cells if HCT < 25.Red blood cells if HCT < 25.• FFP, cryoprecipitate only for coagulation problemsFFP, cryoprecipitate only for coagulation problems

• Septic shockSeptic shock• Early goal directed, large volume therapyEarly goal directed, large volume therapy• Starch is a fluid of choiceStarch is a fluid of choice

ConclusionsConclusions• Resuscitation should be seen as a continuum Resuscitation should be seen as a continuum

in which pre-hospital care, emergency room in which pre-hospital care, emergency room management and intensive therapy merge.management and intensive therapy merge.

• Venous access & fluid therapy are a Venous access & fluid therapy are a necessary part of this continuum but the necessary part of this continuum but the optimum timing for fluid administration optimum timing for fluid administration depends on the circumstances.depends on the circumstances.

• Patient survival is linked to the overall quality, Patient survival is linked to the overall quality, integration, communication & process of care integration, communication & process of care in a trauma system.in a trauma system.

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