fluid and blood resuscitation in abdominal trauma
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“FLUID AND BLOOD RESUSCITATION IN ABDOMINAL TRAUMA:
IMPORTANT TIPS IN CLINICAL PRACTICE FOR SURGEONS”
Dr. T.C. KriplaniProfessor & HeadDepartment of AnaesthesiologyNSCB Medical CollegeJABALPUR (M.P.)
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American College of Surgeons Classes of Acute Hemorrhage
Factors I II III IV
Blood loss <15%(<750ml)
15-30%(750-1500ml)
30-40%(1500-2000ml)
>40%(>2000ml)
Pulse >100 >100 >120 >140
B.P. Normal Normal ↓ ↓↓
Pulse pressure N or ↓ ↓ ↓↓ ↓↓
Capillary refill <2s 2-3s 3-4s >5s
Resp. rate 14-20 20-30 30-40 >40
Urine output ml/hr 30 or more 20-30 5-10 Negligible
Mental status Slightly anxious Mildly anxious Anxious & confused
ConfusedLethargic
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Response to blood loss• ↓Blood volume.• ↓Hydrostatic pressure in capillaries.• Fluid moves from interstitial space to intravascular
space.• Activation of Renin-Angiotensin Aldosterone system.• Na+ retained by kidneys.• α response causes vasoconstriction which shunts
blood from skin, viscera & muscle to preserve blood flow to vital organs.
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Asses the loss quickly on clinical grounds
• If the loss is about 750ml(15%) & patient is haemodynamically stable.
• KVO (Keep the Vein Open)• No fluid required.
• If the loss is about 1500ml(30%) & B.P. 70 - 90mmHg, but stable,
• Start crystalloid solution.• Give oxygen.• Do not raise B.P.(Permissive Hypotension)
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If the loss is 1500-2000ml(30-40%)
• Give crystalloids first, about 2 litres followed by colloid.
• Asses oxygenation of vital organs.• Give oxygen.• Think of blood transfusion.
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If the loss is >2000ml(40%)
• Start crystalloid and colloid.• Give oxygen.• Start blood transfusion.• Monitor oxygenation.• Bring Hb to 7gm%.
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Which crystalloid is better?• Only 25% remain in intravascular compartment.• Dilutional coagulopathy, interstitial & chances of pulmonary edema.
Crystalloid Osmolarity PH Remarks Recommendations
Dextrose 5% 252 4.5
Hypotonic, glucose taken up by cells & water produces oedema.Low PH, ↑blood sugar-brain ischemia.↑CO2 production, ↑lact. Production
NEVER BE USED
Saline 0.9%308(Na 154, Cl 154meq/L)
5.7 Low PH.Hyperchloraemic acidosis is produced. NOT IDEAL
Saline 7.5% 2567(Na 1283, Cl 1283) 5.7
Vol. Exp(250ml→1235ml)Interstitial & cellular dehydration.Rapid rate dangerous.
NOT DESIRED
Lactated Ringer’s solution
273(Na 130, Cl 109, K 4, Ca 3, lactate 28)
6.4Osmolarity near bloodLactate act as buffer.Converted to bicarbonate
BETTER
Normosol
295(Na 140, Cl 98, K 5, Acetate 27, Mg 3)
7.4 Mg. can counteract compensatory vasoconstriction NOT DESIRED
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Which colloid is better?
Albumin Oncotic pressure mm of Hg Vol. expansions Half life
5% 20 70-100% 16-24 hrs
20% 70 300% 16-24 hrs
25% 100 500% 16-24 hrs
• Costly • Allergic reactions• Infection may be transmitted.• Transport of drugs & endogenous substances.
(NOT PREFERRED)
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Synthetic colloids
• Gelatins.• Dextrans.• Starch (HES)
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GELATINS• Prepared by hydrolysis Bovine/Beef collagen.
Mol.wt.(Da)• Haemaccel (Urea linked) 3.5% 30,000
(Na 145, Cl 145, K 5.1, Ca 6.25)• Gelofusine (Succinylated) 4% 35,000
(Na 154, Cl 125)• Cross linked 5.5% 30,000
• PH, osmolarity, COP – Near to blood.• Vol. expansion 70-80%, half life 1-3hrs.• No dose limit, ?Renal damage.• Anaphylaxis .03%, Minor reactions 21%.• WHO has listed Gelatins as essential drug.• Use abandoned in U.S.A. from 1978.• Not approved by F.D.A.• Use has drastically decreased.
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DEXTRANS• Biosynthesized from sucrose by bacteria
leuconostoc messenteroides.• Dextran 70 (6%)
• Osmolarity 280-324• COP 20-30 mm of Hg.• Vol.Exp. 100%• Half life 5-6hrs.• Max. dose(daily) 1.5gm/kg.
• Anaphylactoid reaction, Allergic reaction• Interference with cross matching.• ↑ bleeding tendency.
NOT USED NOW
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DEXTRAN 40 (10%) (Lomodex, Plasmex-40)• Available in normal saline or in 5% dextrose.• Dose 8-10ml/kg/day.
• Osmolarity 280-324• COP 40-60 mm of Hg.• Vol.Exp. 150-200%• Half life 3 hrs.
• Anaphylactoid reactions, allergic reactions.• Interference with cross matching.• Maximum volume expansion.• May produce severe cellular dehydration.• Reduce blood viscosity, improves tissue perfusion.
AT TIMES USED TO IMPROVE MICROCIRCULATION
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STARCH (Hydroxy Ethyl Starch)H.E.S.
• Made from Amylopectin(Hydrolysis & Hydroxy-ethylation).
• Derived from maize or sorghum or potatoes.• Can be classified into
• High molecular wt. (1st Generation)(4,50,000)
• Medium MW (2nd Generation)(2,00,000 – 1,30,000)
• Low MW (3rd Generation)(70,000)
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Physiochemical properties of different H.E.S. preparations
HES 70/.5
HES 130/.4
HES 200/.5
HES 200/.5
HES 450/.7
Concentration 6% 6% 6% 10% 10%
Oncotic pressure mm. of Hg 30-36 36 30-37 55-60 25-30
Volume expansion 100% 100% 100% 130% 100%
Half life (hrs) 1-2 2-3 3-4 3-4 5-6
Maximum dose ml/kg 33 50 33 33 20
Effect on hemostasis 0 Negligible + ++ +++
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H.E.S.(Contd.)• HES 130/.4 improves tissue perfusion and
oxygenation.• May ameliorate capillary leakage.• Hyperviscosity of urine. ? Renal tubular damage.
But 130/.4 is safe.• Some H.E.S. is taken up by reticuloendothelial
system and induce pruritis.• PH around 5.5.(Acidic)• H.E.S. 130/.4 is preferred colloid at present.
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Indications of Blood Transfusion
• Human tolerance to Acute Normovolemic Blood loss is about Hb 7gm%.(21-25% HCT).
• Start blood transfusion if blood loss > 30-40%.• FWB(Fresh Warm Blood) is preferred.
(Experience of American Medics in Afghan & Iraq war 6000 units of FWB was transfused)
(Crit Care Med. July 2008)• Beware of complications of massive blood
transfusion.
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MOST IMPORTANT IS CLINICAL MONITORING
1. B.P. (Invasive more reliable in shock) Radial +(80), Brachial +(70), Carotid +(60) Pulse : Volume
2. Capillary refill time goes on ↑.3. Hb estimation unreliable in acute blood loss.
(may take 8-12hrs to stabilise)4. C.V.P. (may not change upto 30% loss)5. Urine output (hrly.)
(Lack of urine output in acutely hypovolemic patient is renal success, not renal failure)
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CLINICAL MONITORING(Contd.)6. Measure O2 extraction (good marker of hypovolemic shock)
Pulse oximetry SVO2Normal >95% >65Mild hypovolemia >95% 50-65Severe hypovolemia >95% <50• O2 extraction of >50%. Hypovolemic shock usually lactate > 4m.mol/L.
7. End Exp. CO2 (through nasal prongs) gives online measure of success or failure of volume resuscitation.(If pulmonary circulation decreases, End Exp.CO2 goes on decreasing)
8. Bicarbonate estimation is a good marker of tissue perfusion and oxygenation.• Normal BE ± 3 m.mol/L• Mild base def. -2-5 m.mol/L• Moderate -6-14 m.mol/L• Severe >-15m.mol/L
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BEWARE OF LETHAL TRIAD
• Hypothermia• Acidosis • Coagulopathy
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