outline history of fluid resuscitation clinical trial animal studies human studies guideline ...
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Outline
History of fluid resuscitation Clinical trial
Animal studiesHuman studies
Guideline Controversies Conclusion
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Trauma Trauma had long been a major cause of preventable
deaths worldwide.
One-third of trauma deaths because the victims bleed to death within the first several hours
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Lethal triad In the past, high volume resuscitation strategies was
used to reverse haemorrhagic shock
However, still a number of patient develop lethal triad and leads to mortality
Acidosis, hypothermia, coagulopathy
Can be due to the injury, or due to resuscitation
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History of Fluid resuscitation Controlled hemorrhage animal models in
1950s.
Wiggers insert a IV catheter, allow the animal to bleed and maintain a predetermined level of hypotension
Fluid deficit was corrected with crystalloid 3 times the blood loss
Lead to traditional fluid replacement regimen of 3:1 crystalloid: blood
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Wiggers’ model may not be accurateBlood pressure is controlled by investigator
by controlling the blood loss through the iv catheter
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Aggressive fluid resuscitation Early aggressive fluid resuscitation was
used routinely in Vietnam War in 1970s
Coincidentally, ARDS was commonly described
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1980s Uncontrolled haemorrhagic models were
developed to simulate blunt traumamaximal vasoconstrictionthrombus formation
Animal study : Aggressive resuscitation with isotonic crystalloidIncrease blood pressure and increase blood
lossDid not reduce mortality
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Hypotensive Resuscitation In haemorrhagic shock patient, hypotension and
vasoconstriction help to stalilized the clot
Increasing the blood pressure places additional stress on formed clot
Blood pressure greater than 90mmHg associated with higher risk of re-bleeding
Hypotensive resuscitation aim at keeping the blood pressure low enough while maintaining perfusion of end organ.
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Hypotensive Resuscitation Walter Cannon proposed it in 1918
“If the pressure is raised before the surgeon is ready to check any bleeding that may take place, blood that is sorely needed may be lost”○ The preventive treatment of wound shock○ JAMA 70:618-621
George Higginson Professor of PhysiologyWho invented the word ‘homeostasis’
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MAP 0
MAP 80
MAP 40
By AortotomyMAP 40mmHg group had better survival than MAP 80mmHg groupMap 40mmHg group also had less blood loss
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2003 Hypotensive resuscitation improved
mortality compared to traditional resuscitation
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How about Human Studies?
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Prospective controlled trial
Single centre
Penetrating torso injury with SBP < 90mmHg○ Exclude: pregnant, age <16, revised trauma score 0, fatal
gunshot to head, not requiring operation
Immediate Resuscitation (309)•traditional resuscitation with crystalloid
Delayed Resuscitation (289)•Withhold IV Fluid until arrival to operative theatre
VS
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Delayed resuscitation:•Less fluid and packed cell given
Delayed resuscitation: pre op•Lower SBP•Better Hb, plt, clotting profile
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Delayed resuscitation:•Improved survival
•(62% vs 70%)•Shorter length of stay
Delayed resuscitation:•Trend of less ARDS
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Randomized controlled trial
Single centre
Trauma patient with SBP <90mmHg Exclude: pregnant, CNS injury/ impaired consciousness, age >55, history
of DM/ IHD
Target SBP > 100mmHg (55) VS Target SBP 70mmHg (55) Titrating Crystalloid or blood product Fluid restriction to lower BP Until active bleeding was stopped
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SBP 114 +-12 VS SBP 100 +- 17 Similar survival: 92.7%
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Cochrane Review Timing and volume of fluid administration for patients
with bleeding (2003)
We found no evidence from randomized controlled trials for or against early or larger volume of intravenous fluid administration in uncontrolled haemorrhage.
While increasing fluids will maintain blood pressure, it may also worsen bleeding by diluting clotting factors.
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That was 10 years ago
Few more studies published recently
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Retrospective cohort study
Single centre
Including patient with emergent damage control laparotomy Exclude: age <18, pregnant, die on scene or during OT
VSNormotenive group (282) Hypotensive group (108)
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Hypotensive group:• Better:
• temp, heart rate, plt, INR, fibrinogen, pH, base value, lactate
• Fluid:• Less fluid given (13.9L vs 5L)• Less RBC, plasma, platelet transfusion
• Survival:• 24hr survival ( 97% vs 88%)• 30day survival ( 86% vs 76%)
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Ongoing RCT
Single centre
Trauma patients with SBP <90mmHg need laparotomy or thoracotomy Exclude: age >45, <14, pregnant, history of IHD/CVA, head injury
Minimum blood pressure to trigger further resuscitation If spontaneously MAP higher than target, no further action
VSTarget Intra-opMAP 50mmHg
Target Intra-op MAP 65mmHg
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Survival
MAP 50mmHg had better 24hr survivalreduced transfuion requirementLess coagulopathy
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So Which way is correct
Consequences of aggressive fluid resuscitation and bursting the clot
Consequences of hypotension and decreased organ prefusion
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Different Parties have different practice
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ATLS
Everyone gets 2 liters of crystalloid initiallyRespondersTransient responders
○ rebolus or blood for ongoing bleedingNon-responders
○ blood for serious ongoing bleeding
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NICE guideline
Recommendation on traumaAdults and older children
○ IV fluid should not be administered if radial pulse is present
○ 250ml IV fluid should be given if pulse cannot be felt
○ Burns, Blast injuries, Head injuries exception to permissive hypotension
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US Army
Stop bleeding 500ml fluid if
○ No radial pulse or○ Decrease mental status
If positive response, stop fluids
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Something is still missing
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Unsolved problems
Concept of hypotensive resuscitation is clear
But the definition is not!○ Different studies use different definition
SBP? MAP? Limit crystaloid? Complete withhold or titrate against target BP?
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Unsolved problems
Application in concomitant head injury patient?
○ Need to maintain CPP
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Unsolved problemsApplication in concomitant head injury
patient?○ Lack of human study on this area○ Animal study: Stern 2000
Swine model on uncontrolled haemorrhage and brain injury- MAP 60 vs 80- Survival: MAP 60 better and MAP 80- Similar ICP and cerebral blood flow
Draw back: no long term neurological outcome
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Unsolved problems
Duration of hypotensive resuscitation before irreversible damageLack of consensus
○ In Dutton’s studiesMean duration is 2.57 hourSimilar survival between 2 group
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Difficult area for research Heterogeneous definition of hypotensive
resuscitation
Heterogeneous group of trauma patientsUS: both penetrating and blunt traumaUK: most blunt trauma and head injury
Ethical issue, difficult to recruit trauma patient
Limited paper focus on this topic
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Conclusion Aggressive fluid resuscitation in trauma case may not be
totally beneficial
Multiple animal studies demonstrate benefits of hypotensive resuscitation
Equivocal result from human studies. Yet more recent studies demonstrate beneficial effect of hypotensive resuscitation
Different parties had different practice worldwide
Ongoing RCT may help to provide more evidence in near future
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