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Frederick A. Moore MD November 8, 2012

Resuscitation Beyond the Abdominal Compartment Syndrome ( ACS ). Frederick A. Moore MD November 8, 2012. Objectives. Discuss 4 advances in trauma care that occurred in the 1980s that caused an epidemic of ACS in 1990s.

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Frederick A. Moore MD November 8, 2012

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  1. Resuscitation Beyond the Abdominal Compartment Syndrome (ACS) Frederick A. Moore MD November 8, 2012

  2. Objectives • Discuss 4 advances in trauma care that occurred in the • 1980s that caused an epidemic of ACS in 1990s. • 2) Discuss implementing and studying a ICU resuscitation • protocol that helped us recognize that ACS is iatrogenic. • 3) Discuss fundamental changes in early management of • patients who arrive with severe bleeding to eliminate ACS.

  3. Advances in Trauma Care in 1980s Epidemic of ACS in the mid 1990s

  4. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented Resuscitation Epidemic of ACS in the mid 1990s

  5. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented Resuscitation High Volume Trauma Centers with Shock Trauma ICU Epidemic of ACS in the mid 1990s

  6. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented Resuscitation Epidemic of ACS in the mid 1990s

  7. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented Resuscitation Early High Volume Isotonic Crystalloid Resuscitation to Achieve Normal Blood Pressure as Standard of Care Epidemic of ACS in the mid 1990s

  8. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented Resuscitation Epidemic of ACS in the mid 1990s

  9. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented Resuscitation Severely injured patients do not bleed to death in OR Epidemic of ACS in the mid 1990s

  10. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented ICU Resuscitation Epidemic of ACS in the mid 1990s

  11. Advances in Trauma Care in 1980s Trauma System Development Advanced Trauma Life Support Damage Control Surgery Goal Oriented ICU Resuscitation Problematic gut edema in the nonresponders Epidemic of ACS in the mid 1990s

  12. Memorial Hermann Hospital UT Houston Medical School Memorial Hermann Hospital UT Houston Med School Moved to Houston in December 1995 Fffffff

  13. LIFE FLIGHTFOUNDED IN 1976 Dr James H “Red” Duke Jr

  14. BLUNT TRAUMAPLUS SHOCK A Decision Making Conundrum

  15. Computerized Clinical Decision Support (CCDS) For Mech Vent Of ARDS LDS Hospital Salt Lake City, Utah LDS Hospital Salt Lake City, Utah Alan Morris MD Tom East PhD

  16. “Significant problems we face cannot be solved at the same level of thinking we were at when we created them.” Albert Einstein

  17. J Trauma 2002 J Trauma 2001 J Trauma 2001 J Trauma 2002 J Trauma 2001 Bruce McKinley Matt Sailors Bioengineer Informatics Expert

  18. Bedside Algorithm DENVER GENERAL HOSPITAL

  19. Crit Care Med 1988 William Shoemaker

  20. PRCT’s TESTING “SUPRANORMAL DO2” RESUSCITATION DOES IT REDUCE MORTALITY?

  21. DG MOF Database Met inclusion criteria Started 1997 On ICU admission: art, PA, NG tonometer catheters baseline ABG, Hb, lactate No > 600 DO goal Yes 2 Monitor: > 1) Hb (PRBC; Hb 10 ) lactate, BD, PrCO > 2) volume (LR; PCWP 15 ) 2 bladder pressure Q 4h (reassess sooner if Q 4h (reassess sooner if abnormal) abnormal) 3) Optimize CI - PCWP (Starling curve) 4) low dose Inotropes No 24 hours? 24 hours? 5) vasopressor Yes stop resuscitation stop resuscitation Echocardiography standard ICU care standard ICU care

  22. ICU Shock Resuscitation Me Algorithms Matt • Iterative process • Evaluation / testing at each step • Never “done” – always monitoring / refining

  23. COMPUTER DIRECTED RESUSCITATION OF MAJOR TORSO TRAUMA Bruce A. McKinley, R. Matthew Sailors, Christine S. Coconour, Alicia Valdivia Rosemary M. Kozar, and Frederick A. Moore J Trauma 2002 J Trauma 2002 Standard of Care in 1999

  24. HOW PATIENTS RESPOND TO INTERVENTIONS PROSPECTIVELY COLLECT DATA J Trauma 2002 J Trauma 2002

  25. REFINEMENTS IN THE PROTOCOL ONGOING DATA ANALYSIS J Trauma 2002 J Trauma 2002

  26. Mm Ann Surg Sept 2000 Ann Surg Sept 2000 George Velmahos Los Angeles County

  27. January 2001 Computerized Protocol Met inclusion criteria goal Changed DO 2 On ICU admission: art,PA, NG tonometer catheters baseline ABG, Hb, lactate Yes > 500 No DO goal 2 Monitor: > 1) Hb (PRBC; Hb 10 ) lactate, BD, PrCO > 2) volume (LR; PCWP 15 ) 2 bladder pressure Q 4h (reassess sooner if Q 4h (reassess sooner if abnormal) abnormal) 3) Optimize CI - PCWP (Starling curve) No 4) low dose Inotropes 24 hours? 5) vasopressor Yes stop resuscitation standard ICU care Echocardiography

  28. STANDARD OF CARE Field / ED / OR / IR Suite  ATLS “ Damage Control ” surgery Early triage to the ICU Optimize systemic perfusion Jim Cross SAVES LIVES

  29. STANDARD OF CARE Field / ED / OR / IR Suite  ATLS “ Damage Control ” surgery Early triage to the ICU Optimize systemic perfusion SAVES LIVES – BUT ??????? ABDOMINAL COMPARTMENT SYNDROME Open abdomens Organ failure Prolonged ICU stays

  30. PRIMARY ACS ASSOCIATED ABDOMINAL INJURIES Case Reports in the 1980s

  31. PRIMARY ACS ASSOCIATED ABDOMINAL INJURIES Case Reports in the 1980s Recognized Entity by mid 1990s

  32. PRIMARY ACS ASSOCIATED ABDOMINAL INJURIES

  33. SECONDARY ACSNO ABDOMINAL INJURIES Case Reports in the late 1990s

  34. SECONDARY ACSNO ABDOMINAL INJURIES Case Reports in the late 1990s Recognized Entity by early 2000s

  35. SECONDARY ACSNO ABDOMINAL INJURIES CASE SERIES

  36. SECONDARY ACSNO ABDOMINAL INJURIES CASE SERIES

  37. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D., Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D. Shock 2003 Am J Surg 2002 Zsolt Balogh Visiting Research Fellow Hungarian Trauma Surgeon

  38. #2 Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., John B. Holcomb, M.D., Charles C. Miller, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, RN Drue N. Ware, M.D. and Frederick A. Moore, M.D. J Trauma 2002 J Trauma 2003 J Trauma 2002

  39. #2 Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., John B. Holcomb, M.D., Charles C. Miller, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, RN Drue N. Ware, M.D. and Frederick A. Moore, M.D. J Trauma 2002 J Trauma 2003 J Trauma 2002 # 3 # 3 Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D., Rosemary A. Kozar, M.D.,Ph.D., Charles C. Cox, M.D.and Frederick A. Moore, M.D. Am J Surg 2003

  40. # 4 Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, R.N. R. Mathew Sailors, B.S.,Frederick A. Moore, M.D. Arch Surg 2003 152 Resuscitation Protocol Patients 85 Patient 16 months ending Jan 2001 DO2IGoal > 600 71 Patient 16 months after Jan 2001 DO2IGoal > 500

  41. GROUPS WERE SIMILAR PRIOR TO ICU ADMIT

  42. SvO2 CARDIAC INDEX BASE DEFICIT LACTATE P = 0.07

  43. P < 0.05 P = 0.07

  44. * p< 0.05 IAH = UBP > 20 mm Hg

  45. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D., Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D. Shock 2003 Shock 2003 Am J Surg 2002 Epidemiology of Primary and Secondary ACS Surprizingly Early Decompressive Lap ~ 12 hrs Accurately Predict within 3 hrs after ED Arrival Strongly Associated with MOF and Death

  46. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D., Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D. Shock 2003 Shock 2003 Am J Surg 2002 ACS and ICU Resuscitation Protocol Impending ACS patients are non-responders Decreasing D02 goal decreased ACS, MOF & Death

  47. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D., Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D. Shock 2003 Shock 2003 Am J Surg 2002 ACS is not an ICU resuscitation problem It starts in the ED in patients arriving with severe bleeding Fundamental changes in early care of these patients

  48. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D., Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D. Shock 2003 Shock 2003 Am J Surg 2002 ACS is not an ICU resuscitation problem It starts in the ED in patients arriving with severe bleeding Fundamental changes in early care of these patients

  49. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D., Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D. Shock 2003 Shock 2003 Am J Surg 2002 ACS is not an ICU resuscitation problem It starts in the ED in patients arriving with severe bleeding Fundamental changes in early care of these patients

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