Fluid Management of Geriatric Trauma

1
Fluid Management of Geriatric Trauma

• David Antonenko, MD, Ph.D.
• Professor and Director of Surgical Education
• University of North Dakota Department of Surgery

2
Immediate vs Delayed Fluid Resuscitation in
Trauma

• Immediate
  Delayed
• 
  Resuscitation Resuscitation
• SBP ( mm Hg) 79 46
  72 43
• Hb (g/dl) 11.2 2.6
  12.9 2.2
• RTS 5.4 2.1
  5.6 2.1
• GSW () 65
  67
• Survival () 62
  70
• Bickell,WH et al, NEJM 331(17)1105-1109,1994
  

3
Immediate vs Delayed Fluid Resuscitation in
Trauma

• Immediate
  Delayed
• 
  Resuscitation Resuscitation
• SBP ( mm Hg) 79 46
  72 43
• Hb (g/dl) 11.2 2.6
  12.9 2.2
• RTS 5.4 2.1
  5.6 2.1
• GSW () 65
  67
• Survival () 62
  70
• AGE 31 11 31 10
• Bickell,WH et al NEJM 331(17)1105-1109, 1994

4
Geriatric Trauma Prevalence of Pre-existing
disease

• Age 16-64 Age
  64
• Disease Prevalence Mortality
  Prevalence Mortality
• Cardiovascular 3.8 13.0 33.9
  54.1
• Respiratory 0.9 3.0 5.4
  14.3
• Renal 0.1 0
  1.0 50.0
• Diabetes 1.9 1.5 9.0
  17.1
• Liver 0.4
  18.8 1.0 25.0
• Cancer 0.2 28.2 1.3
  40.0
• Perdue, et al J.Trauma
  45(4)805-810, 1998

5
Cardiac Changes with Aging

• ?Contractility
• ? Maximal heart rate
• ? Compliance
• ? Afterload
• Diastolic dysfunction

6
Cardiac Changes with Aging

• ?Contractility
• ? Maximal heart rate
• ? Compliance
• ? Afterload
• Diastolic dysfunction
• ?Cardiac Output

7
Vascular Changes with Aging

• ? Vascular compliance
• ? Receptor function
• ? Vascular volume
• ? Sympathetic responsiveness

8
Vascular Changes with Aging

• ? Vascular compliance
• ? Receptor function
• ? Vascular volume
• ? Sympathetic responsiveness
• ?Systolic Blood Pressure

9
Geriatric TraumaEndpoints of resuscitation(Scale
a, T. et al, J. Trauma 30(4) 129-136, 1990)

• End points of resuscitation
• Cardiac index 4 l/min
• Hct 30
• Inotropes if necessary
• Oxygen consumption index 170m./min/M²

10
Geriatric TraumaEndpoints of resuscitation(Scale
a, T. et al, J. Trauma 30(4) 129-136, 1990)

• End points of resuscitation
• Cardiac index 4 l/min
• Hct 30
• Inotropes if necessary
• Oxygen consumption index 170m./min/M²
• Survival 7 not optimized vs 53 optimized

11
Geriatric Trauma End points of
ResuscitationVelmahos,G. et al Ann Surg. 232(3)
409-418, 2000

• End points of resuscitation
• Systolic Blood pressure gt 100 mm hg.
• Hct 30
• Urine 1 ml/kg/hour
• Base deficit lt -3
• Cardiac Index gt 4.5 l/min/M²
• PaO2/FiO2 gt 200

12
Geriatric Trauma End points of
ResuscitationVelmahos,G. et al Ann Surg. 232(3)
409-418, 2000

• End points of resuscitation
• Systolic Blood pressure gt 100 mm hg.
• Hct 30
• Urine 1 ml/kg/hour
• Base deficit lt -3
• Cardiac Index gt 4.5 l/min/M²
• PaO2/FiO2 gt 200
• No patient over the age of 50
• achieved optimal values

13
Trauma Outcome Age 70

• Group 1 (n 260)
  Group 2 (n76)
• Mean age 77
  78
• Blunt injury 96.2
  93.4
• Death (ISSgt15) 53.8
  34.2
• Death (ISSgt20) 68.4
  46.9
• Demetriates, D. et al, Brit J. Surg.891319-1322,2
  002

14

• Early invasive hemodynamic monitoring and
  judicious use of vasoactive drugs (after
  appropriate fluid rescuscitation) ---should be
  recommended for any geriatric patient with
  significant injuries.
• Jacobs, et al, J. Trauma (54)391-416, 2003

15
Base Deficit and Fluid ResuscitationMortality
Rates()

• Base Deficit Agelt 55 Age gt55
• Normal (2 to -2) 5 18
• Mild (-3to -5)
  8 23
• Moderate (-6 to -9) 19 60
• Severe (lt -10 )
  46 80
• Davis,J. et al. J. Trauma 45(5)873-877, 1998
  

16
Base Deficit and Fluid Resuscitation

• Category Mean SBP Mean HR
  Mortality
• (mm Hg)
  (per min) ()
• I (-2) 132
  96 14
• II ( -2 to 2) 128
  91 13
• III (2 to 6) 125
  97 16
• IV (6 to 10) 120
  99 30
• V ( gt 10 ) 104
  105 64
• Rixen, D. et al, Shock 15(2)83-89, 2001

17
Geriatric TraumaPitfalls in Fluid Management

• 1. Assume that normal blood pressure and heart
  rate equate to normovolemia

18
Geriatric TraumaPitfalls in Fluid Management

• 1. Assume that normal blood pressure and heart
  rate equate to normovolemia
• 2. Infuse fluids based on actual weight rather
  than lean body mass weight

19
Geriatric TraumaPitfalls in Fluid Management

• 1. Assume that normal blood pressure and heart
  rate equate to normovolemia
• 2. Infuse fluids based on actual weight rather
  than lean body mass weight
• 3. Fail to account for co-morbid conditions or
  medications

20
Geriatric TraumaPitfalls in Fluid Management

• 1. Assume that normal blood pressure and heart
  rate equate to normovolemia
• 2. Infuse fluids based on actual weight rather
  than lean body mass weight
• 3. Fail to account for co-morbid conditions or
  medications
• 4. Fail to aggressively monitor patients in the
  early stages of resuscitation

21
Geriatric TraumaPitfalls in Fluid Management

• 1. Assume that normal blood pressure and heart
  rate equate to normovolemia
• 2. Infuse fluids based on actual weight rather
  than lean body mass weight
• 3. Fail to account for co-morbid conditions or
  medications
• 4. Fail to aggressively monitor patients in the
  early stages of resuscitation
• 5. Fail to optimize resuscitation including the
  use of blood transfusions

22
Geriatric Trauma Care

• Transfer to a trauma center if resources are not
  available
• In patients over 80 years, trauma center
  mortality was 8 compared to 56 in non trauma
  centers
• McKinley, et al Arch Surg. 135688-695, 2000

23
Fluid Resuscitation in Geriatric Trauma

• 1. There is no level 1 or level 2 data to
  support resuscitation endpoints.
• 2. Level 3 recommendations optimize the
  patient
• a. invasive monitoring
• b. Cardiac index 4.0 l/min/m²
• c. Base deficit -3

24

• Welcome to Grand Forks and the 3rd Annual Rural
  Surgery Symposium

25
(No Transcript)