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Fluids and Blood in Trauma

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  1. Fluids and Blood in Trauma Charles E. Smith, MD Professor of Anesthesia MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio

  2. Objectives • Overview of trauma • Dx + Tx of shock • Hypotensive resuscitation • Crystalloid + blood products • Intraop bleeding • Cell salvage • O2 carrying solutions • rFVIIa

  3. “Drugs, ETOH, + stupidity have given me a steady paycheck for 30 yrs” Pat Dixon MHMC OR nurse

  4. Trauma Costs • Leading cause of death, ages 1 - 44 yrs • 60 million injuries annually in USA • 30 million require medical care • 3.6 million require hospitalization • 9 million are disabling • 300 k = permanent; 8.7 million= temporary • Costs are staggering: > $100 billion annually, or 40% of health care $ ATLS Provider Manual

  5. Goals of Fluid & Blood Therapy • Restore DO2, treat injuries, maintain CPP • Prevent progression of shock • Repay cellular O2 ‘debt’ • Restore coagulation • Endpoints: normalization of multiple variables- pH, lactate, BE, urine, BP, HR, SPV, SV, pt/ptt, SvO2, CI, DO2, VO2

  6. Oxygen Delivery: DO2 • DO2 = (CaO2 x CO x 10) + (PaO2 x 0.003) • CaO2 = Hg x 1.39 x % sat • CaO2 ~ 1/2 Hct, assume CO 5 L/min, 100% sat • Hct 40 CaO2 20 CO 5 DO2 1000 • Hct 30 CaO2 15 CO 5 DO2 750 • Hct 20 CaO2 10 CO 5 DO2 500 • Hct 10 CaO2 5 CO 5 DO2 250

  7. Oxygen Debt • 1. Full recovery possible • 2. Delayed repayment of O2 debt • 3. Excessive O2 deficit w lethal cell injury • Ref: Siegel JH. Trauma: Emergency Surgery and Critical Care

  8. Estimating Oxygen Debt • Base deficit • Lactate • pH • Mixed venous O2

  9. Arterial Pulse Waveform Analysis • SPV= difference between maximal + minimal values of systolic BP during PPV •  down: normally ~ 5 mm Hg due to  venous return • SPV > 15 mm Hg, or  down > 15 mm Hg: • highly predictive of hypovolemia • LidCO/ PulseCO monitor: SPV, SV, SVV Jonas MM. Curr Opin Crit Care 2002;8:257-61

  10. Hemorrhagic Shock • Class I: < 750 ml, < 15% blood volume: • crystalloid • Class II: 750-1500 ml, 15-30% blood volume • crystalloid • Class III: 1500-2000, 30-40% blood vol • crystalloid, red cells • Class IV: > 2000, > 40% blood vol • crystalloid, red cells ITACCS 2003 Monograph on Massive Transfusion. www.itaccs.com/programs/Trans.pdf

  11. Hypotensive Resuscitation • Attempts to normalize BP with fluids & blood during uncontrolled hemorrhage: • disrupts clot, ­ risk bleeding + mortality • Animal model of uncontrolled hemorrhage: • gp 1- no surgery, no fluid: 100% mortality @ 150 min • gp 2- no fluid, surgery+fluid: 50% @ 90 m, 90% @ 3 d • gp 3- hypo resusc, MAP 40, surgery+fluid: no initial deaths, 40% @ 3 d • gp 4- resusc to MAP 80, surgery+fluid: 80% @ 90 min, ­ blood loss, all died J Am Coll Surg 1995;180:49

  12. Hypotensive Resuscitation, contd • Randomized trial, penetrating torso trauma, urban center: immediate v. delayed fluids • ­ mortality • ­ LOS • ­ complications in immediate gp • Conclusions: • Delayed fluid resuscitation acceptable if rapid dx + tx of injury Bickell et al: NEJM 1994;331:1005

  13. Dutton et al: J Trauma 2002;52:1141 • RCT, trauma pts w SBP < 90; excluded head injury: • Gp 1- fluid resusc to SBP 100 • Gp 2- fluid resusc to SBP 70 • No difference in survival: 93%, although  ISS in gp 2 [23.9 v 19.5] • Duration of bleeding similar between gps: ~ 3 h

  14. Crystalloids and Colloids • LR: slightly hypotonic 273 mOsm/L, contains Ca [do not mix with blood] • 0.9% saline: isotonic, large volumes may cause hyperchloremic metabolic acidosis • D5W: hypotonic, hyperglycemia worsens cerebral ischemia • Hetastarch: Hespan > 20 ml/kg may cause coagulopathy; Hextend better choice Boldt J: Can J Anesth 2004;51:500-13. Review

  15. Hypertonic Fluids • Rapid volume expansion:­ BP + CO • ¯ tissue edema, ICP, brain water • Improved neuro function, CPP, + survival after TBI • Resuscitation fluid of choice for prehospital TBI [Europe]

  16. SAFE Study: NEJM 2004;350:2247 • Multicenter trial: 4% albumin vs. 0.9% saline in hypovolemic ICU pts • RBCT, Australia +NZ, n=6997 • Excluded cardiac surgery, liver transplants +burns • No difference in mortality (21%), ICU (6 d) or hospital (15 d) LOS, vent days (4.5 d), new MOF • Albumin gp reqd less volume overall • Sepsis:  mortality w saline, P=0.09 • TBI:  mortality w albumin , P=0.009

  17. Indications for Transfusion • Acute blood loss + Hct < 25%: frequently • Hct < 20% or Hg < 6 g/dl: almost always • Coagulopathy: factors, platelets • Clinical judgement: CV status, age, pH, BE, additional blood loss, cardiac output, SvO2, tissue oxygenation • Use of single trigger not recommended www.asahq.org/publicationsAndServices/blood_component.html

  18. Anemia and Death • Critical DO2- point at which VO2 becomes dependent on DO2 • Elderly Jehovah’s Witness, 4500 mL blood loss, Hct  9 • Critical DO2 was 184 mL/m2/minor 5 mL/kg/min • ~ 350 mL/min/ 70 kg

  19. Anemia + Myocardial Ischemia • 52 y.o. male, high speed MCA, T10 fx, hemothorax, rib fx, pleural effusions, femur fx, widened mediastinum but negative CT • No head injury, Jehovah’s Witness • Day 1: Hct 20%, Day 2: Hct 13% • Erythropoietin, folic acid, B12, Fe: Hct  20 by day 10

  20. Anemia + Myocardial Ischemia • GA with thio, fent, vec, volatile • EBL 250 ml • Postop: • HR 136 • BP 80/50 • Hg 4.8 • Rx: phenylephrine, esmolol, neostig 6 mm ST  lead II

  21. Hebert et al: N Engl J Med 1999;340:409 • Multicenter, prospective, randomized trial of restrictive v. liberal RBC transfusion • Population: Canadian ICUs, n=4470 • 1o Diagnosis: trauma-20%, respiratory-30%, CVS-20%, GI-15%, CNS or Sepsis-5% • Restrictive: Hg 7-9, Liberal: Hg 10-12 • Conclusions: restrictive at least as effective, + possibly superior to liberal. • Exception: acute MI, unstable angina

  22. Complications of Transfusion • Impaired O2 release from Hg • Immunosuppression + infection • leuko reduced at MHMC since 8/15/01 • Coagulopathy • Hypothermia •  Ca,  K,  pH • Transfusion-related acute lung injury • Hemolytic transfusion reaction

  23. Changes in O2 Transport • P50: PO2 at which Hg is 1/2 saturated with O2 at 37 C, pH 7.40 • After 15 days storage: •  2,3 DPG •  deformability + access to capillaries • Implications: tissue hypoxia + ischemia Fitzgerald et al: CCM 1997;25:726. London, Ontario. Marik: JAMA 1993;269:3024

  24. Aged Blood • > 14 d:  proinflammatory mediators in non-leuko reduced blood • > 15 d: O2 uptake not improved acutely despite  Hg (septic ICU patients) • > 21 d:  MOF after trauma [Zallen: Am J Surg 1999;178:570] • > 28 d:  pneumonia after cardiac surgery [odds ratio 2.7] [Leal-Noval: Anesthesiology 2003;98:807] • > 28 d: VO2 not  in septic animals w supply dependent anemia [Fitzgerald: CCM 1997;25:726]

  25. Red Cell Transfusions @ MHMC N=385 trauma pts requiring surgery w/in 24 h admission, 2003-4

  26. Age of Red Cells @ MHMC N=385 trauma pts requiring surgery w/in 24 h admission, 2003-4

  27. Causes of Intraoperative Bleeding • Surgical • Hypothermia • Hemodilution w crystalloids + colloids •  coag factors, platelets + RBCs • Consumption of coag factors + platelets at site of injury • Colloids (e.g., Hespan) + hemostasis defect • DIC: • tissue trauma, TBI, shock • Other: • Preop defect, coumadin, antiplatelet meds, fibrinolysis

  28. Incidence of Hypothermia in Trauma @ MHMC N=385 trauma pts requiring surgery w/in 24 h admission, 2003-4

  29. Level 1 System H-1000 • Aluminum heat exchanger w counter current 42 oC circulating water bath • Two pressures chambers for rapid infusion • H-1200 has automatic air detection

  30. FMS 2000 Rapid Infusor • Integrated volumetric infusion pump • Magnetic induction heater • Ultrasonic air detection + line pressure sensor coupled to automatic shut off

  31. Forced-Air Warming • Efficacy + safety proven • ­ temp 1-2 oC/h • Inexpensive + non-invasive • Maintains thermoneutral environment • ¯ efficacy • vasoconstriction • insufficient surface area covered Sessler DI: Anesthesiol Clin North Am 1994;12:425

  32. Coagulation Factors •  Fibrinogen, F V + F VIII •  PT, aPTT • 1.5 to 1.8 x N • POC testing • Coagulopathy corrected with FFP, 10-15 ml/kg [Not Platelets] Murray et al: Anesthesiology 1988;69:839

  33. Platelet Works Uses standard hematology cell counting procedure. Example: baseline count = 211,000; ADP (agonist) count = 8,000; Function = (211-8)/211 x 100 = 96%

  34. Contribution of RBCs to Hemostasis • RBCs modulate biochemical + functional responsiveness of platelets • RBCs optimizes interaction of platelets w injured endothelium • RBCs  bleeding time in anemic patients w thrombocytopenia • Hct 30-35% may be necessary to sustain hemostasis in bleeding pts during massive trx Hardy JF et al: Can J Anesth 2004;51:293-310. Groupe d'Interet en Hemostase Perioperatoire

  35. Emergency Transfusion • O neg pRBC • no antigens, universal donor • contain small amt plasma w anti-A and anti-B ab • If > 2 units O neg pRBC: • crossmatch or continue with O neg • Type specific uncrossmatched • Risk of hemolytic trx rx ~ 1:1000

  36. Hemolytic Transfusion Reaction • ABO incompatibility: recipient antibody coats + destroys donor cells • Accounted for 182 deaths: more than 1/2 MD/nurse error; mortality 20-60% • Look for hemoglobinurina, bleeding diathesis, hypotension • Verify + identify each donor unit

  37. Cell-Salvage • Transfuse directly after collection or “wash” • Salvage rate: up to 50% • Savings: ~ 1-2 units allogeneic blood • Processing eliminates most leukocytes, platelets, activated factors, plasma Hg, cytokines, cell fragments, other debris • Hct of processed blood: 50-60%,  2-3 DPG v. allogeneic

  38. Evaluation of Cell Salvage @ MHMC • Retrospective review of 50 patients, Jan 1-June 17, 2003 w Fresinius CATS • Elective surgery: 74%; emerg: 26% • M/F: 60%/40% • Average EBL: 2.7 +4.2 L • Average volume returned: 2 units [0.6 + 0.9 L], or 22% of overall blood loss MHMC Research Exposition, 2003

  39. Cell Salvage @ MHMC: Results

  40. Cell Salvage • Disadvantages: • requires dedicated technical support • risk of air embolism w infusion under pressure • risk of suctioning thrombogenic material: Avitene, QuickClot, Gelfoam/thrombin, Costasis, • leukocyte activation + fat particles: use filter- e.g., Pall Leukoguard • controversial: infected wounds, tumor cells, amniotic fluid, urine • Appropriate for trauma, vascular, cardiac, ortho, + other major blood loss surgeries

  41. PolyHeme® • “Poly SFH-P Injection” • Supports life without donated blood • Immediately available • Universally compatible •  risk of disease transmission • Allows rapid, massive infusion • Shelf-life more than 1 year www.northfieldlabs.com/polyheme.htm

  42. PolyHeme Study, Northfield Phase III study to assess the survival benefit of PolyHeme® when given to severely injured and bleeding patients in hemorrhagic shock, starting at the scene of injury + continuing 12 hr postinjury in the hospital. Multicenter-12 hospitals. http://clinicaltrials.gov/show/NCT00076648

  43. Assessment of Eligibility • Inclusion criteria: • Adults w blunt or penetrating trauma • Apparent blood loss due to injury • Shock w SBP  90 mmHg at the scene of injury • Exclusion criteria: • GCS  5 or other evidence of severe head injury (e.g., blown pupil or posturing) • Asystolic or requires CPR prior to the start of infusion • Known objection to blood products http://clinicaltrials.gov/show/NCT00076648

  44. rFVIIa • Created to treat subgroup of hemophilia patients who developed antibodies, or inhibitors, to FVIII + IX • Multiple reports of ‘off-label’ use for rescue therapy of MVB after exsanguinating hemorrhage: trauma, major surgery, cirrhosis • Mechanism of action: • complexes w TF  activates FX to Fxa, + FIX to FIXa. • Fxa + other factors, converts prothrombin to thrombin • leads to formation of hemostatic plug by converting fibrinogen to fibrin + inducing local hemostasis. www.us.novoseven.com/

  45. rFVIIa for Acquired Coagulopathy • Prospective, non-randomized study, n=29 • Use of drug approved by senior MD •  bleeding in all cases • PT 17.5  9.3 +  INR to 0.6 • 15 long-term survivors • No thrombus formation • Deaths: irreversible shock, sepsis, or TBI Dutton + Scalea: J Trauma 2003;55:208 [Abstract]

  46. Pitfalls in Fluid + Bloods for Trauma 1. Failure to appreciate severity of associated injuries head trauma, shock, pulmonary contusion, hemothorax, SCI, tension pneumo, blunt + penetrating cardiac injury 2. Failure to appreciate amount of blood loss + prevent hypothermic coagulopathy 3. Failure to utilize damage control surgery 4. Failure to utilize point-of-care / stat lab 5. Failure to utilize cell-washing • Ongoing studies to determine role of O2 carrying solutions + rFVIIa

  47. Trauma Chain of Survival • ITACCS Website: www.itaccs.com/ • Programs and courses • Trauma Research, Trauma Prevention • Trauma Care Journal • On line CME