Towards the perfect fluid strategy: Fluid strategy in hemorrhagic shock Sibylle A. Kozek-Langenecker Evangelic Hospital Vienna

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

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 Definition: hemorrhage

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

mod. Jacob 2012

45 litres

intracellular space 30 litres

15 litres extracellular space

12 litres interstitial space

3 litres intravascular space

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

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

infusion therapy fluid volume substitution replacement extracellular intravascular crystalloid colloid Physiology-based fluid strategy in hemorrhagic shock AND

pure water Pharmacodynamics

isotonic crystalloid Pharmacodynamics

urine output extravascular deficits insensible perspiration evaporation Fluid substitution Lamke. Acta Chir Scand 1977; 143: Jacob M, Chappell D, Rehm M. Lancet 2007; 369: ml/kg/h

Excessive crystalloid substitution Jacob. Anaesthesist 2007, 56: Hypervolemia

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

isooncotic colloid Pharmacodynamics

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

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

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

Context-sensitivity on the cover

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

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

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

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

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

Dosing of fluids target parameters & safety aspects

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

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

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

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

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

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

Side effects on hemorrhage dextran > pentastarch > tetrastarch/gelatins ~ albumin maximum daily dose in massive bleeding ?

Haas. Anesth Analg 2008;106: 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 MCFblood loss HS-HES11 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 = p =0.004 Small volume resuscitation

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

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

FRACTA 2013 February 7 th -9 th 2013 in Prague safe the date

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