Towards the perfect fluid strategy: Fluid strategy in hemorrhagic shock

1. Towards the perfect fluid strategy: Fluid strategy in hemorrhagic shock Sibylle A. Kozek-Langenecker Evangelic Hospital Vienna www.perioperativebleeding.org sibylle.kozek@aon.at

2. Conflicts of interest Honoraria for lectures and travel reimbursement: B. Braun Fresenius Kabi

3. Definition: hemorrhage Severe bleeding: > 20% blood volume loss Massive bleeding: > 100% blood loss in 24 h > 50% blood loss in 3 h > 150 ml/min in 20 mins > 1.5 ml/kg/min in 20 mins > 6 U PRBC in 24 h Martinowitz. J Thromb Haemost 2005; 3: 640

4. Physiological basics intravascular interstitial intracellular water water Na+ Na+ Na+ K+ K+ K+ protein protein protein protein

5. Physiological basics mod. Jacob 2012

6. 45 litres

7. intracellular space 30 litres

8. extracellular space 15 litres

9. interstitial space 12 litres

10. intravascular space 3 litres

11. Pathophysiological basics in hemorrhagic shock: intravascular compartment tissue perfusion in hemorrhagic shock: intravascular compartment tissue perfusion

12. Fluid strategy in hemorrhagic shock in hemorrhagic shock: stopp bleeding intravascular compartment tissue perfusion

13. Physiology-based fluid strategy in hemorrhagic shock infusion therapy fluid volume substitution replacement extracellular intravascular crystalloidcolloid AND

14. Pharmacodynamics pure water

15. Pharmacodynamics isotonic crystalloid

16. Fluid substitution urine output extravascular deficits insensible perspiration evaporation 0.5-1 ml/kg/h Lamke. Acta Chir Scand 1977; 143: 279-84 Jacob M, Chappell D, Rehm M. Lancet 2007; 369: 1984-6

17. Excessive crystalloid substitution Hypervolemia Jacob. Anaesthesist 2007, 56:747-64

18. Keep the glycocalyx happy ☺ Chappell 2008 Chappell D. Cardiovascular Research 2009; 83:388–396

19. Pharmacodynamics isooncotic colloid

20. Volume efficacy Van der Linden. Review. Can J Anaesth 2006;53:S30-9

21. Direct measurement of volume efficacy Proof of concept: isooncotic colloids act intravascular

22. Context-sensitivity of volume efficacy Jacob. Lancet 2007, 369: 1984-6 in hemorrhagic shock: highest volume efficacy

23. Context-sensitivity on the cover

24. Pathomechanisms of massive bleeding Kozek. In: Yearbook of Intensive Care and Emergency Medicine 2007:847 Tissue trauma + Consumption Cut vesicles Tissue trauma + Hyperfibrinolysis Thrombomodulin / Protein C Pre-existing disorders Anticoagulation Antiplatelet drugs Blood loss Fluid resuscitation + Dilution Triad of Malfunction (hypothermia, acidosis, hypocalcaemia)

25. Dilutional coagulopathy reversal hemodilution baseline Fries. Anesth Analg 2002; 94:1280 Innerhofer. Anesth Analg 2002; 95: 858

26. The ideal intravascular resuscitation fluid good volume efficacy no coagulopathic side effect no other relevant side effects

27. 500 mL Hct: 38-45% Plt: 150-400K Coags: 100% 1:1:1 ratio concept: á 600 ml Armand & Hess. Transfusion Med Rev 2003 volume efficacy ? coagulopathy ? harms/burdens ? Plt 5.5x1010 50 mL FFP 80% 250mL PRBC Hct 55% 335 mL 1U PRBC + 1U PLT + 1U FFP: • factor activity 65% • Platelet count 87K • Hct 29%

28. Concentrate-based concept: á 50 ml Schöchl. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012; 20: 15 Minerva Anestesiol 2005 JSTEM 2012

29. Dosing of fluids target parameters & safety aspects

30. Acidosis ≠ acidosis Gunnerson. Crit Care 2006; 10:R22

31. The FIRST Study: Lactate clearance Fluids In Resuscitationin Severe Trauma • similar static hemodynamic measurements between groups • superior tissue perfusion after HES James. Br J Anaesth 2011;107:693

32. ESA guideline 2012Management of severe periOP bleeding 9-10 of November 2012 Prague, Czech Republic

33. Colloidal patient safety issues „therapeutic window“ overload endothelial damage intraabdominal hypertension inadequate volume therapy death adverse outcomes coagulopathy & bleeding kidney dysfunction itching anaphylaxis dose of colloid

34. Colloidal safety measures „therapeutic window“ individualized dosing IA pressure monitoring ? fluid monitoring and individualised dosing avoidance of adverse outcomes Choice of colloid anamnesis, awareness & symptomatic treatment dose of colloid

35. Potential side effects of colloids - Coagulopathy beyond hemodilution Anesthesiology 2005;103:654. Transfus Altern Transfus Med 2007;9:173. Best Pract Res Clin Anaesth 2009; 23: 225

36. Side effects on hemorrhagedextran > pentastarch > tetrastarch/gelatins ~ albumin maximum daily dose in massive bleeding ?

37. Small volume resuscitation 30 pigs after 60% blood volume withdrawal intervention: 4 ml/kg hypertonic saline (7.2%) / HES (6% 200/0.62) 50 ml/kg 4% gelatin 41 ml/kg 6% tetrastarch MCF blood loss HS-HES 11 mm (10,11) 725 ml (375, 900) tetrastarch 3.5 mm (2.3,4) 1600 ml (1500,1800) gelatin 4.5 mm (3,5.8) 1625 ml (1275,1950) p = 0.0034 p =0.004 Haas. Anesth Analg 2008;106:1078

38. Small volume resuscitation & outcome shock + blunt/penetrating trauma: no difference in mortality BUT increased mortality in subgroup without RBCs Bulger EM. JAMA. 2010; 304:1455-64 shock + traumatic brain injury: no difference in mortality and neurological outcome Cooper D. JAMA 2004; 291;1350-1357

39. Conclusions heterogeneous fluid/procoagulant concepts existin a pathophysiology-based infusion concept: fluid substitution: balanced isotonic crystalloids volume replacement: isooncotic colloids hemodynamic monitoring: preload & metabolic parameters > HR & pressure parametersavoid hypervolemia monitoring of colloidal side effects:dependent on molecule, dosing, timing, endothelial barrier

40. FRACTA 2013 February 7th-9th 2013 in Prague safe the date sybille.richter@fresenius-kabi.com

41. Thank you for your attention ! www.perioperativebleeding.org sibylle.kozek@aon.at