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Fluid Resuscitation in Traumatic Critically Ill Patients

Fluid Resuscitation in Traumatic Critically Ill Patients. Aug 21, 2006 Ri 林 殿 閔. Patterns of Traumatic Injury. Penetrating injury – ongoing significant blood loss is expected Blunt injury – blood loss may be occult or contained and significant or limited

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Fluid Resuscitation in Traumatic Critically Ill Patients

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  1. Fluid Resuscitation in Traumatic Critically Ill Patients Aug 21, 2006 Ri 林 殿 閔

  2. Patterns of Traumatic Injury • Penetrating injury – ongoing significant blood loss is expected • Blunt injury – blood loss may be occult or contained and significant or limited • Head injury – maintenance of cerebral perfusion pressure • Others: pediatric and obstetric trauma

  3. Shock • Definition: a state of reduced organ perfusion resulting in tissue hypoxia and organ dysfunction • S/S: falling of BP, tachycardia, oligouria, decreased mental status, decreased peripheral pulses, diaphoresis • Main goal of therapy: rapid resuscitation with re-establishment of tissue perfusion using fluid therapy and vasoactive drugs

  4. Hemorrhagic shock • Acute response: • Increased capillary permeability • Reduction in blood flow • Sympathetic compensation by peripheral vasoconstriction • Elevated IL-6 and TNF-alpha • Tissue hypoperfusion and anaerobic metabolism/acidosis • After systemic circulation is restored, reperfusion injury due to free oxygen radicals released during acute hypoxic stage may occur

  5. Traumatic hemorrhagic shock • Acute stage: hemorrhagic shock • May be accompanied with : • Cardiogenic shock • Neurogenic shock • Obstructive shock • Septic shock

  6. Hemorrhagic shock

  7. Traumatic hemorrhagic shock • Trauma triad of death after hemorrhagic shock: (1) Hypothermia (2) Acidosis (3) Coagulopathy

  8. Traumatic hemorrhagic shock • Phase 1: The period from injury to definite surgical care and homeostasis • Phase 2: The period during and immediately after definite surgical procedure • Phase 3: The period in ICU following definitive care and characterized by established critical illness

  9. Phase 1: pre-hospital /pre-operative fluid therapy • Traumatic hypotension without a head injury: no evidence suggest that pre-hospital fluids are beneficial • Delayed fluid resuscitation has better outcome than immediate resuscitation in penetrating torso injuries • The evidence supporting delayed or limited prehospital resuscitation in blunt trauma is less clear

  10. Phase 2: perioperative fluid management • It is unclear whether targeting cardiac output or oxygen delivery to specific defined goals results in improved clinical outcomes • Maximized stroke volume using fluids titrated against a measure of blood flow is supported by limited available data

  11. Phase 2: perioperative fluid anagement • The addition of inotropes to achieve specific blood flow or oxygen delivery goals may confer additional advantage but the available data is not conclusive

  12. Phase 3: Critical care fluid management • Fluid strategies are directed at restoring organ function after the combined insult of hypovolemic hypoperfusion, surgery and trauma induced inflammatory response • Maintaining a normal circulating volume (cardiac output) is a priority • Targeting oxygen delivery goals has been demonstrated to be harmful in established critical illness

  13. Trauma Fluid Resuscitation • Severity of hemorrhagic shock • Age • Co-morbid disorder • Injury types • Concurrent head or spinal injury • Pulmonary edema

  14. Types of Fluid • Crystalloid solutions • Colloid solutions • Gelatins • Dextrans • Hydroxyethyl starches (HES) • Albumin and plasma-protein fraction • Blood & blood substitutes

  15. Crystalloids • Solutions in water of inorganic ions and small organic molecules, either glucose or sodium chloride based.

  16. Colloids • A homogeneous, non-crystalline substance consisting of large molecules or ultramicroscopic particles of one substance dispersed through a second substance • Principal types of semisynthetic colloid molecules: gelatins; dextrans; and HES • Human plasma derivatives: albumin, FFP and immunoglobulin solutions

  17. Colloids

  18. Key characteristics of artificial colloids • Magnitude and duration of plasma volume expansion • Hemorreological characteristics • Hemostatic effects • Interaction with endothelial and inflammatory cells • Adverse drug reactions • Cost

  19. Gelatins, Dextrans, HES • Gelatins: prepared by hydrolysisof bovine collagen. commonly available preparation -- succinylated gelatin (Gelofusin) • Dextrans: high-MW D-glucose polymers joined largely into linear-branched macromolecules • HES: synthesized from amylopectin, a waxy starch derived from maize or sorghum

  20. Albumin and plasma-protein fraction • Human albumin: a naturally occuring monodiperse colloid • FFP and plasma-protein fraction: a more polydisperse human-derived colloidal solution with significant amounts of higher-MW proteins -- globulins

  21. Blood Substitutes: hemoglobulin solutions • At an early stage of development and probably some way from routine clinical use • HBOC (Hemoglobic-based oxygen-carrying compounds) • PBOC (Perflourocarbon-based oxygen-carrying compounds) • Have a linear O2Hb dissociation profile and specific pharmacological effects

  22. Thank you for your attention !!

  23. Hemorrhagic shock

  24. Schematic diagram of capillary memebrane

  25. Crystalloids

  26. Colloids

  27. HES solutions

  28. HBOC

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