dr. dr. ike sri redjeki, sp.an-kic alamat kantor : smf/dept.anestesiologi & terapi intens...

DR. Dr. Ike Sri Redjeki, Sp.AN-KIC

Alamat Kantor : SMF/Dept.Anestesiologi & Terapi Intens FKUP/RSHS

Jl. Pasteur No. 38 Bandung 40161

Telp/Fax Kantor : 022-2036285/022-2038306

Alamat Rumah : Komplek Permata Indah E-12 Bandung

Telp/Fax rumah : 022-6031526

No.HP : 0811230514

Tempat/Tgl Lahir : Jakarta, 16 Desember 1950

Email : -

Profesi : Dokter Spesialis Anestesi

Jabatan :

1. Kepala SMF/Dept.Anestesiology&Terapi Intensif FKUP/RSHS

2. -

Fluid Resuscitation and Transfusion for

Trauma

Ike Sri RedjekiRS Hasan Sadikin/ FK. UNPAD

Bandung

When Fluid Resuscitation is Needed ?

In SHOCK !

SHOCK

INADEQUATE CARDIAC OUTPUT

Peripheral circulatory

failure

True Hypovolaemia

Blood lossPlasma lossSaline loss

Dehydration

Apparent Hypovolaemia (vasodilation)

SepsisNeurogenicAnaphylaxis

Adrenal insufficiency

“Pump Failure”

CardiogenicPulmonary Embolus

TamponadeTension pneumoTx

Concept of pathogenesis of physiologic changes in Multiple Trauma

Trauma

Inflammation Haemorrhage Fibrinolysis

Shock

Tissue Hypoxia and Acidosis

Activation of haemostasis & endothelium

Coagulopathy

Primary Survey

• Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms

• ABCDEs of trauma care– A Airway and c-spine protection– B Breathing and ventilation– C Circulation with hemorrhage control– D Disability/Neurologic status– E Exposure/Environmental control

In Trauma Patients

What is the Recommendation ?( Sphan et al critical Care 2013,17:R76)

• Initial resuscitation and prevention further bleeding • Minimal elapsed time– The time elapsed between injury and operation be

minimised for patients in need of urgent surgical bleeding control – Grade 1A

– Adjunct touniquet use to stop life threatening bleeding from open extreemity injuries in the pre surgical setting – Grade 1B

What is the Recommendation ?( Sphan et al critical Care 2013,17:R76)

• Patients presenting with haemorrhagic shock and an unidentified source of bleeding undergo immediate further investigation – Grade 1B

• Chest• Abdominal cavity• Pelvic ring

Further CT for haemodynamically stable patient

What is the Recommendation ?( Sphan et al critical Care 2013,17:R76)

• It is not recommended the use of single Hct measurement as an isolated laboratory marker of bleeding – Grade 1B

• Serum lactate or base deficit measurement as sensitive test to estimate and monitor the extent of bleeding and shock – Grade 1B

• Routine practice to detect post traumatic coagulopathy include the early, repeated and combined measurement of PT, APTT, fibrinogen and platelets – Grade 1C

Recommendation Of Fluid Therapy

Recommendation of Fluid Therapy in Trauma Patients

• Fluid therapy be initiated in the hypotensive bleeding trauma patient – Garde 1A

• Crystalloids first choice – Grade 1B• Avoid hypotonic solution RL sol• Coloids used within the prescribed limit for each

solution• Hypertonic solution for unstable penetrating torso

trauma – Grade 2C

Recommendation of Fluid Therapy in Trauma Patients

• Administration of vasopressors to maintain to target MAP if no response to fluid therapy – Grade 2C

• Or inotropic myocardial dysfunction • Maintain temperature > 35 degree C – Grade 1C• Target Hb 7 – 9 gr%

• Damage control resuscitation is now the predominant focus upon arrival in hospital

• Crystalloid delivery should be minimized, as it can be associated with harm

• Trauma-induced coagulopathy is a common problem caused by dilution and consumption of clotting factors, hypothermia and acidosis

• Evidence suggests it can be decreased by early delivery of blood products

• The best resuscitation appears to be with whole blood rather than component therapy

• Can 1:1:1 ( Plasma : RBC : Platelets ) ever be an adequate substitute for fresh whole blood, or should blood banks consider a return to using whole blood?

• Tranexamic acid should be consider and is significantly cheaper ( compare to Factor VII )

• Giving unnecessary plasma and platelets should be discouraged in order to reduce the risk of transfusion-related acute lung injury

• Poin of care coagulation tests may aid decision making and reduce unnecessary transfusionst of care

• Massive transfusion protocols, improve communication and delivery of blood products to the patient

• Enable clinicians to give fresh plasma up front, rather than giving red blood cells initially and plasma later

How about Crystalloid ?

• Giving a significant amount of crystalloid upfront on admission a common practice leading to various problem : Abdominal compartment syndrome ( ACS ), Acute Resp Distress Syndrome (ARDS ), multiple organ failure

• Giving crystalloid > 1.5 liters in emergency department independent risk factor for mortality > 70 years old OR 2.89 and Non elderly patients OR 2.09

• High volume ( > 3 liters ) > 70 years OR 8.61, • Using Colloid decreased lactate level and < renal

injury better tissue resuscitation

Transfusion Strategy

• Masive transfusion : > 10 unit RBc within 24 hour• A significant advantage of Warm Fresh Whole

Blood over component therapy contain full amount of platelets

• Even vs best practice component therapy 1: 1:1

Fresh Whole Blood >> effective than Component

Damage control resuscitation(on admission)

• Rapid control of surgical bleeding• Early and increased use of red blood cells, plasma

and platelets in 1: 1: 1 ratio• Limitation of excessive crystaloid use• Prevention and treatment of hypothermia,

hypocalcemia, and acidosis• Hypotensive resuscitation strategies

Sphan et al Critical Care 2013; 17:R76 – 1-45

Current recommendation for blunt trauma is to administer just enough fluid to maintain perfusion

Rapid, high-volume fluid administration is discouragedRecommendation : Target BP systolic 80 – 90 mmHg, until

major bleeding stop afterwards optimalized

In patients combined haemorragic shock and severe TBI (GCS < 8) MAP > 80 mmHg

Permissive Hypotension in Traumatic Brain Injury

• Oxygenation and Blood Pressure– Hypoxemia (<90% SpO2)

and/or hypotension (<90 mm Hg systolic) are associated with poor outcomes.

– Pulse oximetry and blood pressure must be monitored.

– Continuous waveform capnography beneficial

CPP = MAP- ICPSlightly higher systolic

pressure may be required to maintain CPP in TBI

Target of Fluid Ressuscitation

DO2 = (CO x Hb x SpO2 x 1.34 ) + (PaO2 x 0,003)↓

O2 Balance O2ER= VO2 / DO2 = 25%↓

VO2 = O2 Consumption

CONTROL CENTER IN THE MICROENVIRONMENT

http://www.glycocalyx.nl/background.php

Glycocalyx

Structure of Glyccocalyx

Reitsma S, et al. Eur J Physiol 2007; 454:345–359

Glycocalyx

Endothelial cell

Protect the Vessel Wall

ELECTRONE MICROGRAPH OF MYOCARDIAL CAPILLARY

Gouverneur M, Van den berg B, Nieuwdorp M, Stroes E, Vink H. Journal of Internal Medicine 2006; 259: 393–400

Alteration of Glycocalyx leads to extravasation

• Alteration in the composition of the glycocalyx following exposure to an inflammatory insult is one of the earliest features of endothelial activation

• It is now accepted that TNFα, oxidised lipoproteins, lipopolysaccharide, thrombin, ischaemia/reperfusion, hyperglycaemia and growth factors all cause glycocalyx disruption via the action of proteases

Hypervolemia ↓

Leads to disruption of the glycocalyx

Conclusion

• First hour of trauma management ABC’s primary survey and secondary survey being accomplished as fast as possible

• The time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control

• Damage control resuscitation on admission • Shock in trauma cases mostly hypovolemia restore the iv volume• Fluid resuscitation avoid further damage • Keep the blood pressure not to high before hemorrhage being

controlled• Avoid hypervolemia• Target of resuscitation balance between DO2 and VO2

Conclusions

• Blood transfusion Masive transfusion can be predicted ( BE -10 and Hb

• Prefer to use WFWB than blood component • Blood component 1 : 1 : 1 • Use plasma first to prevent traumatic

coagulopathy

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