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UPMC Critical Care

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  1. UPMC Critical Care www.ccm.pitt.edu

  2. Hypotensive Resuscitation Samuel A. Tisherman, MD, FACS, FCCM University of Pittsburgh Professor Departments of Critical Care Medicine and Surgery

  3. Trauma case • 23 yo male • GSW epigastrum • HR 140, BP 80/p • Distended, tender abdomen

  4. Standard Dogma • Advanced Trauma Life Support guidelines • 1-2 liters lactated Ringer’s, then ?blood • Normalize blood pressure ASAP

  5. Walter B. Cannon • “Hemorrhage in a case of shock may not have occurred to a marked degree because blood pressure has been too low and the flow too scant to overcome the obstacle offered by a clot. 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.” Cannon WB, Fraser J, CowellEM. JAMA1918:618-621

  6. Pop the clot

  7. While there is still a hole in a named blood vessel, what is the best fluid resuscitation strategy to keep the victim alive until hemostasis can be achieved and to promote intact survival?

  8. Aggressive fluid resuscitation • More bleeding • Increased pressure • Decreased viscosity • Hemodilution • Loss of clotting factors • Decreased O2 delivery • Loss of buffering capacity

  9. Coagulopathy of trauma Hess JR et al. J Trauma 2008;65:748-754.

  10. Hypotensive Fluid Resuscitation • Laboratory studies • Clinical studies • Unanswered questions

  11. Uncontrolled hemorrhagic shock Stern, et al. AcadEmerg Med, 1995.

  12. Limited Fluid Resusc- Survival I – MAP 40 II – MAP 80 III – No fluid Kowalenko, et al. J Trauma,1992.

  13. Uncontrolled Hemorrhagic Shock Model Capone, et al. JACS, 1995.

  14. Survival After Uncontrolled HS Groups: 1=Untreated controls 2=No prehospital FR 3=FR to MAP 40 mmHg 4=FR to MAP 80 mmHg Capone, et al. JACS, 1995.

  15. HBOC and UHS • Pigs bled to SBP 35 mmHg+flat EEG • 15 min HS --> 30 min resuscitation • Phase 1 (3 groups) • LR • Blood • rHb2.0 (second generation HBOC) • Phase 2 - DCLHb Malhotra, et al. J Trauma, 2003.

  16. rHb2.0 LR DLCHb LR Blood Blood Malhotra, et al. J Trauma, 2003.

  17. HBOC and UHS Malhotra, et al. J Trauma, 2003.

  18. Grade V Liver Injury Model

  19. The Fluid Showdown • 2 liters NS • 2 liters LR • 500 ml Hextend • 250 ml 7.5% hypertonic saline • with 3% Dextran (HTS) • No fluid (NF) Rihaet al. J Trauma 2011;71:1755 – 1760.

  20. Mean arterial pressure -5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 Time (min) Rihaet al. J Trauma 2011;71:1755 – 1760.

  21. Primary and Secondary Blood Loss Fluids  lower Hct, increased PT, decreased fibrinogen Rihaet al. J Trauma 2011;71:1755 – 1760.

  22. Tissue O2 Rihaet al. J Trauma 2011;71:1755 – 1760.

  23. Base excess Rihaet al. J Trauma 2011;71:1755 – 1760.

  24. Is blood better? Spoerke et al. Arch Surg, 2009.

  25. Is blood better? Spoerke et al. Arch Surg, 2009.

  26. Hypotensive Resuscitation and the Brain Carrillo, et al. J Trauma, 1998.

  27. Hypotensive Resuscitation and the Brain Carrillo, et al. J Trauma, 1998.

  28. Hypotensive Resuscitation and the Brain Carrillo, et al. J Trauma, 1998.

  29. Summary of preclinical studies • You can show whatever you want • Size of the hole • Rate of fluid resuscitation

  30. Houston Delayed Fluid Resuscitation Trial • 598 adults • Penetrating injuries • Torso • SBP <90 mmHg • “Waived consent” • Randomized by odd or even day • Standard ATLS or nothing until OR Bickell, et al. NEJM, 1994.

  31. Houston Delayed Fluid Resuscitation Trial Bickell, et al. NEJM, 1994.

  32. Houston Delayed Fluid Resuscitation Trial Bickell, et al. NEJM, 1994.

  33. Fluids Administered Bickell, et al. NEJM, 1994.

  34. Labs on Arrival Bickell, et al. NEJM, 1994.

  35. Houston Delayed Fluid Resuscitation Trial Bickell, et al. NEJM, 1994.

  36. Canadian Study • IV group compared to no IV group retrospectively • Patients matched for prehospital criteria • Actual prehospital time not that different Sampalis et al. J Trauma 1997;43:608 – 617.

  37. Outcomes Sampalis et al. J Trauma 1997;43:608 – 617.

  38. Outcomes by Time Sampalis et al. J Trauma 1997;43:608 – 617.

  39. Hypotensive Resuscitation • Maryland Shock Trauma • In hospital • Inclusion criteria • SBP <90 mmHg • Ongoing hemorrhage • Blunt or penetrating trauma • Treatment • SBP >100 mmHg • SBP >70 mmHg Dutton, et al. J Trauma, 2002.

  40. Hypotensive Resuscitation Dutton, et al. J Trauma, 2002.

  41. Hypotensive Resuscitation Dutton, et al. J Trauma, 2002.

  42. Hypotensive Resuscitation Dutton, et al. J Trauma, 2002.

  43. Ben Taub Operative Study Morrison et al. J Trauma 2011;70:652 – 663.

  44. Fluids Morrison et al. J Trauma 2011;70:652 – 663.

  45. Postoperative Findings Morrison et al. J Trauma 2011;70:652 – 663.

  46. Survival Morrison et al. J Trauma 2011;70:652 – 663.

  47. Effects of Shock and Resuscitation on Coags FFP is needed along with PRBCs for resuscitation. Lucas and Ledgerwood. J Trauma, 2003.

  48. Non-trauma operative fluids Standard care vs Restricted (to maintain body wt) Brandstrup et al. Ann Surg, 2003.

  49. Non-trauma operative fluids Brandstrup et al. Ann Surg, 2003.