Fluids and Blood in Trauma

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 gt 100 billion annually, or
  40 of health care

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 gt 15 mm Hg, or ? down gt 15 mm Hg
• highly predictive of hypovolemia
• LidCO/ PulseCO monitor SPV, SV, SVV

Jonas MM. Curr Opin Crit Care 20028257-61
10
Hemorrhagic Shock

• Class I lt 750 ml, lt 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 gt 2000, gt 40 blood vol
• crystalloid, red cells

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 _at_ 150
  min
• gp 2- no fluid, surgeryfluid 50 _at_ 90 m, 90 _at_
  3 d
• gp 3- hypo resusc, MAP 40, surgeryfluid no
  initial deaths, 40 _at_ 3 d
• gp 4- resusc to MAP 80, surgeryfluid 80 _at_ 90
  min, blood loss, all died

J Am Coll Surg 199518049
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 19943311005
13
Dutton et al J Trauma 2002521141

• RCT, trauma pts w SBP lt 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 gt 20 ml/kg may cause
  coagulopathy Hextend better choice

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 20043502247

• Multicenter trial 4 albumin vs. 0.9 saline in
  hypovolemic ICU pts
• RBCT, Australia NZ, n6997
• 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, P0.09
• TBI ? mortality w albumin , P0.009

17
Indications for Transfusion

• Acute blood loss Hct lt 25 frequently
• Hct lt 20 or Hg lt 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_compon
ent.html
18
Anemia and Death

• Critical DO2- point at which VO2 becomes
  dependent on DO2
• Elderly Jehovahs Witness, 4500 mL blood loss,
  Hct ? 9
• Critical DO2 was 184 mL/m2/min or 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, Jehovahs 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 1999340409

• Multicenter, prospective, randomized trial of
  restrictive v. liberal RBC transfusion
• Population Canadian ICUs, n4470
• 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

24
Aged Blood

• gt 14 d ? proinflammatory mediators in non-leuko
  reduced blood
• gt 15 d O2 uptake not improved acutely despite ?
  Hg (septic ICU patients)
• gt 21 d ? MOF after trauma Zallen Am J Surg
  1999178570
• gt 28 d ? pneumonia after cardiac surgery odds
  ratio 2.7 Leal-Noval Anesthesiology
  200398807
• gt 28 d VO2 not ? in septic animals w supply
  dependent anemia Fitzgerald CCM 199725726

25
Red Cell Transfusions _at_ MHMC
N385 trauma pts requiring surgery w/in 24 h
admission, 2003-4
26
Age of Red Cells _at_ MHMC
N385 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 _at_ MHMC
N385 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

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

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

35
Emergency Transfusion

• O neg pRBC
• no antigens, universal donor
• contain small amt plasma w anti-A and anti-B ab
• If gt 2 units O neg pRBC
• crossmatch or continue with O neg
• Type specific uncrossmatched
• Risk of hemolytic trx rx 11000

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 _at_ 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

39
Cell Salvage _at_ 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

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.go
v/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, n29
• 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

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