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Endpoints of Resuscitation [in Trauma]. AJ Layon , MD, FACP Professor and Chief Critical Care Medicine University of Florida College of Medicine Gainesville, FL. Basics First. Shock is imbalance of DO 2 and VO 2. Severe Under-Resuscitation in Trauma is Shock.

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endpoints of resuscitation in trauma

Endpoints of Resuscitation [in Trauma]

AJ Layon, MD, FACP

Professor and Chief

Critical Care Medicine

University of Florida College of Medicine

Gainesville, FL

shock is imbalance of do 2 and vo 2
Shock is imbalance of DO2 and VO2

Severe Under-Resuscitation in Trauma is Shock

  • Resuscitation is complete when...
    • O2 debt is repaid
    • Tissue acidosis is eliminated
    • Aerobic metabolism restored
  • …However we define this and with whatever monitors we use to determine endpoints
  • ATLS Manual, 1993
    • An abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation…

Porter JM, Ivatury RR, J Trauma, 1998;44:908.

slide4
Organ Perfusion in Critically Ill Patients

Lecture goals

  • Cellular energetics during "acute illness"
  • Old and new logistics of trauma
  • Systemic organ perfusion monitoring
  • Selective organ perfusion monitoring / goals
slide5
Realistically, prevention of these is how we earn our salary

From the trauma bay to discharge from the ICU

TRAUMA

MOF

SIRS

O2 DEBT

DEATH

RECOVERY

slide6
Cellular energetics

fatty acids

O2

ATP = ADP+Pi+H+

(energy)

O2

slide7
O2

1

Glycolysis

(energy)

(D-glucose to

Lactate

+ 2H+)

= H2O +

H+

+ HCO3-

CO2

2

ADP + ADP = ATP +

AMP

(vasodilatation)

xanthine oxidase,

free O2 radicals

3

CK reaction

(PCr

+ ADP = H + ATP + Cr)

limited to heart, brain, skeletal muscle

4

Lactate / pyruvate

5

NADH / NAD

cytosolic redox status

slide8
Organ Perfusion in Trauma Patients

Clinical parameters

Global and regional

(organ perfusion) parameters

cellularparameters

slide10
MTP: Class III and beyond

Estimated Fluid and Blood Requirements1

(Based on Patient’s Initial Presentation)

Class IV: 65% of

Factors and 75%

Of Plts present

Class I

Class II

Class III

Class IV

Blood Loss (ml)

Blood Loss (%BV)

Pulse Rate

Blood Pressure

Pulse Pressure

(mm Hg)

Capillary Refill Test

Respiratory Rate

Urine Output (ml/hr)

CNS-Mental Status

Fluid Replacement

(3:1 Rule)

Up to 750

up to 15%

< 100

Normal

Normal or

increased

Normal

14 - 20

30 or more

Slightly anxious

Crystalloid

750 - 1500

15 - 30%

> 100

Normal

Decreased

Positive

20 - 30

20 - 30

Mildly anxious

Crystalloid

1500 - 2000

30 - 40%

> 120

Decreased

Decreased

Positive

30 - 40

5 - 15

Anxious and

confused

Crystalloid

+ blood

2000 or more

40% or more

140 or higher

Decreased

Decreased

Positive

> 35

Negligible

Confused -

lethargic

Crystalloid

+ blood

1For a 70 - kg male

rl vs hts hts wins
RL vs HTS: HTS wins

Murine hemorrhagic shock versus

Sham with LR versus Hypertonic Saline

Resuscitation: PMN activation

Deitch, Shock 2003;19:328

Think

TRALI/ARDS / MOSF / ACS

hemorrhage and trauma
Hemorrhage and Trauma
  • New algorhythm in severe trauma:
    • Damage control resuscitation strategy
    • Focused on halting / preventing lethal triad:
      • Coagulopathy
      • Acidosis
      • Hypothermia

Holcomb JB, et al. Ann Surg.2008;248: 447 – 458

old and new paradigms
Old and New Paradigms

Cosgriff N, et al. Predicting life-threatening coagulopathy in the massively transfused patient:

Hypothermia and acidosis revisited. J Trauma. 1997.

Carrico, et al. Transfusion Chapter in Mattox,

Moore and Feliciano

coagulopathy how quick
Coagulopathy: How Quick ?
  • Loss of Coagulation factors
    • 1 Blood volume (BV) - 35% of factors remain
    • 2 BVs – 10% - 15% remain
    • 3 BVs – 5% remain
  • 20% - 30% of activity required for hemostasis
  • Factors also consumed with clotting
  • 1,088 Pts 1993 – 1998
  • Arrival to ED from scene ~ 73 min
  • 24% had coagulopathy (PT > 18, aPTT > 60 sec, TT > 15 sec)
  • Mortality for those with coagulopathy 46% vs 11% in those without

Brohi K, et al: J Trauma, 2003;54:1127

blood co new trauma trends

Blood & Co:New Trauma Trends

MT = > 10 units PRBC / 24 hrs

critical revision of old trauma trends
Critical Revision of Old Trauma Trends
  • Crystalloids are good for you
    • LR developed for diarrhea
  • Fresh whole blood is bad for you
  • Plasma is a bad resuscitation fluid
  • Platelets should be given after the “surgical

bleeding” is controlled

  • Laboratory data are helpful in a rapidly bleeding patient
  • RBCs today do not resemble those studied in the 70’s
  • No data in trauma as whole blood transitioned to component therapy
asa guidelines on ffp transfusion
ASA Guidelines on FFP Transfusion

Blood usually coagulates appropriately when:

Coagulation factor concentrations are at least 20% - 30% of normal

Fibrinogen is > 75 mg / dL

Clinical coagulopathy from dilution does not occur until:

Replacement exceeds 1 BV or

PT / PTT exceeds 1.5 – 1.8 times control values

With hypothermia1

Coagulation enzyme reactions decreased by 10% / °C

1. Armand R, Hess JR: Treating Coagulopathy in Trauma Patients. Trans Med Rev, 2003;17 (3):223 – 231

hemorrhagic shock mtp
Hemorrhagic Shock: MTP
  • 80% to 85% of combat deaths not preventable
    • 66% to 80% of 15% to 20% of survivable combat-related deaths result from hemorrhagic shock
  • Recognition / treatment of coagulopathy important
    • Most Ptsrequiring MTP die within 6 hrsof admit
  • Lethal triad after trauma:
    • Bleeding, hypothermia, acidosis

BorgmanMA, et al.J Trauma.2007;63:805–813

hemorrhagic shock and resuscitation
Hemorrhagic Shock and Resuscitation

BorgmanMA, et al.J Trauma.

2007;63:805–813

mortality by plasma rbc ratio n 246 mt s 2003 2005 military
Mortality by Plasma : RBC Ration = 246 MT’s (2003 – 2005): Military

Borgman MA, et al. J Trauma. 2007;63:805–813

mt civilian
MT: Civilian

466 / 1574 (29.6%) civilian trauma Pts retrospective analysis of registries

No ISS / AIS differences. Overall survival 59%

Range by center: 41% - 74%

Holcomb JB, et al. Ann Surg.2008;248: 447 – 458

ffp ptl
FFP:PTL

Holcomb JB, et al. Ann Surg.2008;248: 447 – 458

mortality vs mean ffp rbc ratio by center and variability civilian
Mortality vs mean FFP / RBC ratio byCenter and Variability: Civilian

Holcomb JB, et al. Ann Surg.2008;248: 447 – 458

Massive transfusion practice guidelines should aim for a 1 : 1 : 1 ratio of FFP : Plts : PRBC

risks of ffp and platelets
RISKS OF FFP and PLATELETS
  • Reports of TRALI from the UK haemovigilanceprogram
    • Suggest risk from FFP ~ 1 in 50,000 to 60,000 units
    • May now be the commonest cause of death from transfusion
    • Is the most frequent serious complication of FFP
  • In most of the TRALI cases arising from FFP
    • Female donors identified as the source of the antibodies
    • ARC recently limited female donors
      • Further lowering risk of a rare complication

Eder AF, et al. Transfusion, 2010;50:1732-1742

Wiersum – Osselton JC, et al. Transfusion,doi: 10.1111/j 1537-2995.2010.02969.x [4 April, 2011]

Rios JA, et al. Transfusion,doi: 10.1111/j.1537-2995.2010.02991.x[11 April, 2011]

risks of ffp and platelets1
RISKS OF FFP and PLATELETS

Eder AF, et al. Transfusion, 2010;50:1732-1742

resuscitation endpoints
Resuscitation Endpoints
  • Historical
    • BP, HR, UOP
    • However...
      • 80% - 85% under-resuscitated when values normalized
        • Elevated lactate
        • Decreased SVO2

Scalea et al, CCM, 1994;22:1610.

Abou-Khalil et al, CCM, 1994;22:633.

bp and coronary autoregulation
BP and Coronary Autoregulation

120

100

80

60

Flow (% of normal)

40

20

0

10

30

50

70

90

110

130

Perfusion pressure (mm Hg)

Hypertrophic

heart

Heart

Bellomo et al. Critical Care 2001;5:294

slide30
Blood Pressure (MAP) is Brain Flow

Zone of Normal

Autoregulation

100

50 mm Hg

80 mm Hg

75

Range of

Hyperfusion

50

65

Cerebral Blood Flow (cc/10g/min)

Normal autoregulation

B

A

Disrupted autoregulation

25

0

0

75

25

50

100

125

150

Mean Arterial Blood Pressure (mm Hg)

additional endpoints of resuscitation
Additional Endpoints of Resuscitation

Oxygen delivery

SvO2 and ScvO2

Arterial base deficit

Arterial lactate

Gastric tonometry……….

Near Infrared Spectroscopy (NIRS)

Physical examination

slide32
Back to basics

Organ Perfusion in Critically Ill Patients

(Valid for Everyone)

  • DO2= Q X CaO2 =

Q X [(Hb x 1.39 x SaO2) + 0.003 x PaO2)]

For a CO = 5 and Hb = 15:

  • DO2 =

1000

mL / min or

620

mL / min / m2

  • VO2 = Q X (CaO2 - CvO2) =

240

mL / min or

170

mL / min / m2

  • O2ER= (CaO2 - CvO2) / CaO2 =

0.27%............or

(SaO2 - SvO2) / SaO2

cytopathic tissue hypoxia in critical illness is proportional to svo 2 ci
Cytopathic Tissue Hypoxia in Critical Illness is Proportional to SVO2 (& CI)

Rs= .61

P < 0.05

Mixed venous oxygen saturation (SvO2) and mitochondrial respiration measured as mitochondrial-dependent reduction of WST-1 (abs, absorbance) for 15 patients with septic shock

RoulosM. Crit Care Med. 2003 Feb;31:353 – 8

slide34
And in fact Net Cumulative VO2 Deficit is much more for Non Survivors.

Shoemaker WC, et al. Chest. 1992;102:208 – 215

optimization of do 2 by optimizing svo 2
“Optimization” of DO2 by Optimizing SVO2 ?

Gattinoni L, et al. N Engl J Med.1995;333:1025 – 1032

optimization of do 2 by optimizing svo 21
“Optimization” of DO2 by Optimizing SVO2 ?

Gattinoni L, et al. N Engl J Med.1995;333:1025 – 1032

slide38
Rivers Protocol: EARLY GOAL (SsvcO2 > 70%)

60

49.2%

P = 0.01 *

50

40

33.3%

30

20

10

0

Standard Therapy

N = 133

EGDT

N = 130

Rivers E, et al. N Engl J Med.2001;345:1368 – 1377

cardiac filling pressures not appropriate to predict response to volume challenge
Cardiac Filling Pressures: Not Appropriate to Predict Response to Volume Challenge

Osman D,etal. Crit Care Med. 2007;35:64 – 68

interpretation of an elevated paop 20
Interpretation of an Elevated PAOP (20)

A. High extracardiac pressure with normal preload

B. Normal extracardiac pressure and increased preload in a normally compliant ventricle

C. Normal / decreased preload of a poorly compliant ventricle

slide42
Scattergram of cardiac index (Cl) vs pulmonary artery wedge pressure (PAWP) with first-order regression line of best fit (Cl = 3.103 + 0.098 x PAWP) (n = 131, r = .418, P < .001)

Scattergram of cardiac index (Cl) vs right ventricular end-diastolic volume index (RVEDVI) with first-order regression line of best fit (Cl = 1.094 + 0.028 x RVEDVI) (n = 131, r = .613, P < .001)

baseline pp predicts volume responsiveness in hypotensive critically ill patients
50

y = 1.01x – 1.46

r2 = 0.85

40

30

Changes in cardiac index (%)

20

10

0

0

10

20

30

40

50

Baseline ΔPP (%)

Baseline ΔPP Predicts Volume Responsiveness in Hypotensive Critically Ill Patients

MichardF, et al. Am J RespCrit Care Med. 2000;162:134 – 138

baseline pp predicts volume responsiveness in hypotensive critically ill patients1
Baseline ΔPP Predicts Volume Responsiveness in Hypotensive Critically Ill Patients

MichardF, et al. Am J RespCrit Care Med.

2000;162:134 – 138

slide48
Lactate and DO2

DO2

LA

Vincent ActaAnaesthesiolScand 1995;39(suppl 107): 261-6

slide49
Persistent Lactic Acidosis =

Decreased Survival

*

VO2

Lactic Acid

DO2

Bakker Chest 1991;99:956-62

NgyenCrit Care Med 2004;32:1637-42

slide50
Increased BD =

Decreased Survival

500

100

%

M

O

R

T

A

L

I

T

Y

80

400

P

A

T

I

E

N

T

S

60

300

Mortality

Number of Pts

40

200

20

100

0

0

0

-5

-10

-15

-20

-25

-30

-35

-40

-45

BASE DEFICIT (mmol/L)

Rutherford et al, J Trauma, 1992;33:417.

slide51
Organ Perfusion in Critically Ill Patients

BE vs MOSF Post Trauma

*

40

35

30

25

BE<=4

BE > 4

20

15

10

5

0

% MOSF

*

p < 0.001

Kincaid, J Am CollSurg,1998;187:384 – 392

persistent base deficit decreased survival
4

* #

3

2

#

1

#

0

-1

-2

-3

-4

-5

-6

Standard base excess (mEq/L)

-7

-8

-9

-10

-11

-12

Survivors

-13

Non survivors

4

2

0

1

3

5

Days after admission

Persistent Base Deficit = Decreased Survival

Park M, et al. Evolutivestandard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal directed therapy: Still outcome markers ? Clinics.2006;61:47 – 52

slide53
Organ Perfusion in Critically Ill Patients

Gastric Tonometry

CO2 freely diffuses in tissues

PCO2in the balloon is in equilibrium with mucosal

PCO2

Arterial HCO3- = mucosal HCO3-

pHi = 6.1 + (log [HCO3-] / mucosal PCO2)

pHi - pHa gap PtCO2- PaCO2gap

Gastric tonometry is based on the principle that tissue production of CO2 rises sharply with tissue dysoxia.

slide54
Organ Perfusion in Critically Ill Patients

Sublingual Capnometer

1) accessible

2) high PC stores

Weil CCM 1999 Vol 27 (7): 1225-29

sublingual pco 2 p sl co 2
Sublingual PCO2 (PSLCO2)

mmHg

30

70

150

MarikPE. Chest 2001;120:923-927

PovoasH, et al. Chest 2000;118:1127-1132

†Weil MH, et al. Crit Care Med. 1999; 27:1225-1229

orthogonal polarization spectral imaging sublingual circulation
Orthogonal Polarization Spectral Imaging: Sublingual Circulation

- Normal

- Hypoperfusion

- Sepsis

De Backer Daniel, et al. Am J RespCrit Care Med. 2002;166:98 – 104

orthogonal polarization spectral imaging sublingual circulation1
Orthogonal Polarization Spectral Imaging: Sublingual Circulation

De Backer Daniel, et al. Am J RespCrit Care Med. 2002;166:98 – 104

ops imaging sublingual circulation
OPS Imaging: Sublingual Circulation
  • 18 consecutive MVPtsin early phase (within 24 h) of septic shock, defined as:
    • Hypotension (MAP <65 mmHg) requiring a pressor agent
      • Dopamine > 5 μg/kg/min or NE
    • In the presence of an infection
  • Pts treated with midazolam, morphine, H2receptor blocker

Creteur J, et al. Intensive Care Med. 2006;32:51–523

near infrared spectroscopy nirs
Near-Infrared Spectroscopy(NIRS)

Continuous, noninvasive tissue oxygen monitor

NIR-light

Detection

Probe

Cuff released

NIR-light

Emission Probe

Baseline

Concentration changes (mM)

Arterial oclusion

Lima AP. Int Care Med. 2005;31:1316 – 1326

near infrared spectroscopy nirs1
Near-Infrared Spectroscopy: NIRS

Uses light transmission and absorption to measure concentration of Hb, StO2 and cyt-aa3 in tissue

Global assessment of oxygenation in arterial, venous and capillary compartments

Limitation

Affected by edema

Application

Brain

Skeletal muscle and visceral ischemia

regional perfusion markers
Regional Perfusion Markers

McKinley et. al., 2000

Severely injured trauma patients

100

1000

90

80

800

70

60

600

50

StO2 (%)

400

40

30

StO2 (20 mm; skeletal muscle)

200

20

StO2 (6 mm; subcutaneous)

10

DO2I

0

0

80

70

60

50

40

PgCO2, gap (mmHg)

30

20

Found the measurement

of tissue oxygenation

correlated well with

oxygen delivery, base

deficit and lactate levels.

PgCO2

20

PgCO2 – PaCO2gap

0

90

8

80

6

70

60

4

50

40

SvO2 (%)

BD (mEq/L), lactate (mM)

2

30

SvO2

20

0

BD

10

lactate

-2

0

0

4

20

8

12

16

24

28

32

36

start

end

TIME (hr)

resuscitation

end point of resuscitation in trauma conclusions
End Point of Resuscitation in Trauma: Conclusions
  • This was a Troglodytic field
    • Now better
    • No ABC, no fast surgeon, no mission accomplished
  • Non-crystalloids resuscitation is the new buzz
    • PRBC / FFP / Plts / Cryoprecitate
  • BP / Pulse / UOP / MS practical but not accurate
  • At some point DO2 / VO2relationship needs to be evaluated and corrected if feasible
  • Biomarkers are very reasonable endpoints, as long as sampled frequently
  • Fancy toys coming………..stay tuned
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