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Endpoints of Resuscitation [in Trauma]

Endpoints of Resuscitation [in Trauma]. AJ Layon , MD, FACP Professor and Chief Critical Care Medicine University of Florida College of Medicine Gainesville, FL. Basics First. Shock is imbalance of DO 2 and VO 2. Severe Under-Resuscitation in Trauma is Shock.

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Endpoints of Resuscitation [in Trauma]

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  1. Endpoints of Resuscitation [in Trauma] AJ Layon, MD, FACP Professor and Chief Critical Care Medicine University of Florida College of Medicine Gainesville, FL

  2. Basics First

  3. Shock is imbalance of DO2 and VO2 Severe Under-Resuscitation in Trauma is Shock • Resuscitation is complete when... • O2 debt is repaid • Tissue acidosis is eliminated • Aerobic metabolism restored • …However we define this and with whatever monitors we use to determine endpoints • ATLS Manual, 1993 • An abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation… Porter JM, Ivatury RR, J Trauma, 1998;44:908.

  4. Organ Perfusion in Critically Ill Patients Lecture goals • Cellular energetics during "acute illness" • Old and new logistics of trauma • Systemic organ perfusion monitoring • Selective organ perfusion monitoring / goals

  5. Realistically, prevention of these is how we earn our salary From the trauma bay to discharge from the ICU TRAUMA MOF SIRS O2 DEBT DEATH RECOVERY

  6. Cellular energetics fatty acids O2 ATP = ADP+Pi+H+ (energy) O2

  7. O2 1 Glycolysis (energy) (D-glucose to Lactate + 2H+) = H2O + H+ + HCO3- CO2 2 ADP + ADP = ATP + AMP (vasodilatation) xanthine oxidase, free O2 radicals 3 CK reaction (PCr + ADP = H + ATP + Cr) limited to heart, brain, skeletal muscle 4 Lactate / pyruvate 5 NADH / NAD cytosolic redox status

  8. Organ Perfusion in Trauma Patients Clinical parameters Global and regional (organ perfusion) parameters cellularparameters

  9. However…Few words on quality of Resuscitation are Necessary Crystalloids Blood FFP Plts

  10. MTP: Class III and beyond Estimated Fluid and Blood Requirements1 (Based on Patient’s Initial Presentation) Class IV: 65% of Factors and 75% Of Plts present Class I Class II Class III Class IV Blood Loss (ml) Blood Loss (%BV) Pulse Rate Blood Pressure Pulse Pressure (mm Hg) Capillary Refill Test Respiratory Rate Urine Output (ml/hr) CNS-Mental Status Fluid Replacement (3:1 Rule) Up to 750 up to 15% < 100 Normal Normal or increased Normal 14 - 20 30 or more Slightly anxious Crystalloid 750 - 1500 15 - 30% > 100 Normal Decreased Positive 20 - 30 20 - 30 Mildly anxious Crystalloid 1500 - 2000 30 - 40% > 120 Decreased Decreased Positive 30 - 40 5 - 15 Anxious and confused Crystalloid + blood 2000 or more 40% or more 140 or higher Decreased Decreased Positive > 35 Negligible Confused - lethargic Crystalloid + blood 1For a 70 - kg male

  11. RL vs HTS: HTS wins Murine hemorrhagic shock versus Sham with LR versus Hypertonic Saline Resuscitation: PMN activation Deitch, Shock 2003;19:328 Think TRALI/ARDS / MOSF / ACS

  12. Hemorrhage and Trauma • New algorhythm in severe trauma: • Damage control resuscitation strategy • Focused on halting / preventing lethal triad: • Coagulopathy • Acidosis • Hypothermia Holcomb JB, et al. Ann Surg.2008;248: 447 – 458

  13. Old and New Paradigms Cosgriff N, et al. Predicting life-threatening coagulopathy in the massively transfused patient: Hypothermia and acidosis revisited. J Trauma. 1997. Carrico, et al. Transfusion Chapter in Mattox, Moore and Feliciano

  14. Coagulopathy: How Quick ? • Loss of Coagulation factors • 1 Blood volume (BV) - 35% of factors remain • 2 BVs – 10% - 15% remain • 3 BVs – 5% remain • 20% - 30% of activity required for hemostasis • Factors also consumed with clotting • 1,088 Pts 1993 – 1998 • Arrival to ED from scene ~ 73 min • 24% had coagulopathy (PT > 18, aPTT > 60 sec, TT > 15 sec) • Mortality for those with coagulopathy 46% vs 11% in those without Brohi K, et al: J Trauma, 2003;54:1127

  15. Blood & Co:New Trauma Trends MT = > 10 units PRBC / 24 hrs

  16. Critical Revision of Old Trauma Trends • Crystalloids are good for you • LR developed for diarrhea • Fresh whole blood is bad for you • Plasma is a bad resuscitation fluid • Platelets should be given after the “surgical bleeding” is controlled • Laboratory data are helpful in a rapidly bleeding patient • RBCs today do not resemble those studied in the 70’s • No data in trauma as whole blood transitioned to component therapy

  17. ASA Guidelines on FFP Transfusion Blood usually coagulates appropriately when: Coagulation factor concentrations are at least 20% - 30% of normal Fibrinogen is > 75 mg / dL Clinical coagulopathy from dilution does not occur until: Replacement exceeds 1 BV or PT / PTT exceeds 1.5 – 1.8 times control values With hypothermia1 Coagulation enzyme reactions decreased by 10% / °C 1. Armand R, Hess JR: Treating Coagulopathy in Trauma Patients. Trans Med Rev, 2003;17 (3):223 – 231

  18. Hemorrhagic Shock: MTP • 80% to 85% of combat deaths not preventable • 66% to 80% of 15% to 20% of survivable combat-related deaths result from hemorrhagic shock • Recognition / treatment of coagulopathy important • Most Ptsrequiring MTP die within 6 hrsof admit • Lethal triad after trauma: • Bleeding, hypothermia, acidosis BorgmanMA, et al.J Trauma.2007;63:805–813

  19. Hemorrhagic Shock and Resuscitation BorgmanMA, et al.J Trauma. 2007;63:805–813

  20. Mortality by Plasma : RBC Ration = 246 MT’s (2003 – 2005): Military Borgman MA, et al. J Trauma. 2007;63:805–813

  21. MT: Civilian 466 / 1574 (29.6%) civilian trauma Pts retrospective analysis of registries No ISS / AIS differences. Overall survival 59% Range by center: 41% - 74% Holcomb JB, et al. Ann Surg.2008;248: 447 – 458

  22. FFP:PTL Holcomb JB, et al. Ann Surg.2008;248: 447 – 458

  23. Mortality vs mean FFP / RBC ratio byCenter and Variability: Civilian Holcomb JB, et al. Ann Surg.2008;248: 447 – 458 Massive transfusion practice guidelines should aim for a 1 : 1 : 1 ratio of FFP : Plts : PRBC

  24. RISKS OF FFP and PLATELETS • Reports of TRALI from the UK haemovigilanceprogram • Suggest risk from FFP ~ 1 in 50,000 to 60,000 units • May now be the commonest cause of death from transfusion • Is the most frequent serious complication of FFP • In most of the TRALI cases arising from FFP • Female donors identified as the source of the antibodies • ARC recently limited female donors • Further lowering risk of a rare complication Eder AF, et al. Transfusion, 2010;50:1732-1742 Wiersum – Osselton JC, et al. Transfusion,doi: 10.1111/j 1537-2995.2010.02969.x [4 April, 2011] Rios JA, et al. Transfusion,doi: 10.1111/j.1537-2995.2010.02991.x[11 April, 2011]

  25. RISKS OF FFP and PLATELETS Eder AF, et al. Transfusion, 2010;50:1732-1742

  26. Resuscitation Endpoints • Historical • BP, HR, UOP • However... • 80% - 85% under-resuscitated when values normalized • Elevated lactate • Decreased SVO2 Scalea et al, CCM, 1994;22:1610. Abou-Khalil et al, CCM, 1994;22:633.

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  28. BP and Coronary Autoregulation 120 100 80 60 Flow (% of normal) 40 20 0 10 30 50 70 90 110 130 Perfusion pressure (mm Hg) Hypertrophic heart Heart Bellomo et al. Critical Care 2001;5:294

  29. Blood Pressure (MAP) is Brain Flow Zone of Normal Autoregulation 100 50 mm Hg 80 mm Hg 75 Range of Hyperfusion 50 65 Cerebral Blood Flow (cc/10g/min) Normal autoregulation B A Disrupted autoregulation 25 0 0 75 25 50 100 125 150 Mean Arterial Blood Pressure (mm Hg)

  30. Additional Endpoints of Resuscitation Oxygen delivery SvO2 and ScvO2 Arterial base deficit Arterial lactate Gastric tonometry………. Near Infrared Spectroscopy (NIRS) Physical examination

  31. Back to basics Organ Perfusion in Critically Ill Patients (Valid for Everyone) • DO2= Q X CaO2 = Q X [(Hb x 1.39 x SaO2) + 0.003 x PaO2)] For a CO = 5 and Hb = 15: • DO2 = 1000 mL / min or 620 mL / min / m2 • VO2 = Q X (CaO2 - CvO2) = 240 mL / min or 170 mL / min / m2 • O2ER= (CaO2 - CvO2) / CaO2 = 0.27%............or (SaO2 - SvO2) / SaO2

  32. Cytopathic Tissue Hypoxia in Critical Illness is Proportional to SVO2 (& CI) Rs= .61 P < 0.05 Mixed venous oxygen saturation (SvO2) and mitochondrial respiration measured as mitochondrial-dependent reduction of WST-1 (abs, absorbance) for 15 patients with septic shock RoulosM. Crit Care Med. 2003 Feb;31:353 – 8

  33. And in fact Net Cumulative VO2 Deficit is much more for Non Survivors. Shoemaker WC, et al. Chest. 1992;102:208 – 215

  34. “Optimization” of DO2 by Optimizing SVO2 ? Gattinoni L, et al. N Engl J Med.1995;333:1025 – 1032

  35. “Optimization” of DO2 by Optimizing SVO2 ? Gattinoni L, et al. N Engl J Med.1995;333:1025 – 1032

  36. Then a number of ER guys showed some magic

  37. Rivers Protocol: EARLY GOAL (SsvcO2 > 70%) 60 49.2% P = 0.01 * 50 40 33.3% 30 20 10 0 Standard Therapy N = 133 EGDT N = 130 Rivers E, et al. N Engl J Med.2001;345:1368 – 1377

  38. Preload End Point ?

  39. Cardiac Filling Pressures: Not Appropriate to Predict Response to Volume Challenge Osman D,etal. Crit Care Med. 2007;35:64 – 68

  40. Interpretation of an Elevated PAOP (20) A. High extracardiac pressure with normal preload B. Normal extracardiac pressure and increased preload in a normally compliant ventricle C. Normal / decreased preload of a poorly compliant ventricle

  41. Scattergram of cardiac index (Cl) vs pulmonary artery wedge pressure (PAWP) with first-order regression line of best fit (Cl = 3.103 + 0.098 x PAWP) (n = 131, r = .418, P < .001) Scattergram of cardiac index (Cl) vs right ventricular end-diastolic volume index (RVEDVI) with first-order regression line of best fit (Cl = 1.094 + 0.028 x RVEDVI) (n = 131, r = .613, P < .001)

  42. 50 y = 1.01x – 1.46 r2 = 0.85 40 30 Changes in cardiac index (%) 20 10 0 0 10 20 30 40 50 Baseline ΔPP (%) Baseline ΔPP Predicts Volume Responsiveness in Hypotensive Critically Ill Patients MichardF, et al. Am J RespCrit Care Med. 2000;162:134 – 138

  43. Baseline ΔPP Predicts Volume Responsiveness in Hypotensive Critically Ill Patients MichardF, et al. Am J RespCrit Care Med. 2000;162:134 – 138

  44. LactateBase Deficit

  45. Lactate and DO2 DO2 LA Vincent ActaAnaesthesiolScand 1995;39(suppl 107): 261-6

  46. Persistent Lactic Acidosis = Decreased Survival * VO2 Lactic Acid DO2 Bakker Chest 1991;99:956-62 NgyenCrit Care Med 2004;32:1637-42

  47. Increased BD = Decreased Survival 500 100 % M O R T A L I T Y 80 400 P A T I E N T S 60 300 Mortality Number of Pts 40 200 20 100 0 0 0 -5 -10 -15 -20 -25 -30 -35 -40 -45 BASE DEFICIT (mmol/L) Rutherford et al, J Trauma, 1992;33:417.

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