1. DR. Dr. Ike Sri Redjeki, Sp.AN-KIC
Alamat Kantor : SMF/Dept.Anestesiologi & Terapi Intens FKUP/RSHS
Jl. Pasteur No. 38 Bandung 40161
Telp/Fax Kantor : /
Alamat Rumah : Komplek Permata Indah E-12 Bandung
Telp/Fax rumah :
No.HP :
Tempat/Tgl Lahir : Jakarta, 16 Desember 1950 -
Profesi : Dokter Spesialis Anestesi
Jabatan :
1. Kepala SMF/Dept.Anestesiology&Terapi Intensif FKUP/RSHS
2. -

2. Fluid Resuscitation and Transfusion for Trauma
Ike Sri Redjeki
RS Hasan Sadikin/ FK. UNPAD
Bandung

3. When Fluid Resuscitation is Needed ?
In SHOCK !

4. SHOCK Peripheral circulatory failure True Hypovolaemia
INADEQUATE CARDIAC OUTPUT
Peripheral circulatory failure
True Hypovolaemia
Blood loss
Plasma loss
Saline loss
Dehydration
Apparent Hypovolaemia (vasodilation)
Sepsis
Neurogenic
Anaphylaxis
Adrenal insufficiency
“Pump Failure”
Cardiogenic
Pulmonary Embolus
Tamponade
Tension pneumoTx
SHOCK

5. Concept of pathogenesis of physiologic changes in Multiple Trauma
Inflammation Haemorrhage  Fibrinolysis
Activation of haemostasis & endothelium
Shock
Tissue Hypoxia and Acidosis
Coagulopathy

6. In Trauma Patients Primary Survey
Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms
ABCDEs of trauma care
A Airway and c-spine protection
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability/Neurologic status
E Exposure/Environmental control

7. What is the Recommendation ? ( Sphan et al critical Care 2013,17:R76)
Initial resuscitation and prevention further bleeding
Minimal elapsed time
The time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control – Grade 1A
Adjunct touniquet use to stop life threatening bleeding from open extreemity injuries in the pre surgical setting – Grade 1B

8. What is the Recommendation ? ( Sphan et al critical Care 2013,17:R76)
Patients presenting with haemorrhagic shock and an unidentified source of bleeding undergo immediate further investigation – Grade 1B
Chest
Abdominal cavity
Pelvic ring
Further CT  for haemodynamically stable patient

9. What is the Recommendation ? ( Sphan et al critical Care 2013,17:R76)
It is not recommended the use of single Hct measurement as an isolated laboratory marker of bleeding – Grade 1B
Serum lactate or base deficit measurement as sensitive test to estimate and monitor the extent of bleeding and shock – Grade 1B
Routine practice to detect post traumatic coagulopathy include the early, repeated and combined measurement of PT, APTT, fibrinogen and platelets – Grade 1C

10. Recommendation
Of Fluid Therapy

11. Recommendation of Fluid Therapy in Trauma Patients
Fluid therapy  be initiated in the hypotensive bleeding trauma patient – Garde 1A
Crystalloids  first choice – Grade 1B
Avoid hypotonic solution  RL sol
Coloids used  within the prescribed limit for each solution
Hypertonic solution  for unstable penetrating torso trauma – Grade 2C

12. Recommendation of Fluid Therapy in Trauma Patients
Administration of vasopressors  to maintain to target MAP  if no response to fluid therapy – Grade 2C
Or inotropic  myocardial dysfunction
Maintain temperature > 35 degree C – Grade 1C
Target Hb  7 – 9 gr%

13. Damage control resuscitation is now the predominant focus upon arrival in hospital
Crystalloid delivery should be minimized, as it can be associated with harm

14. Trauma-induced coagulopathy is a common problem caused by dilution and consumption of clotting factors, hypothermia and acidosis
Evidence suggests it can be decreased by early delivery of blood products

15. The best resuscitation appears to be with whole blood rather than component therapy
Can 1:1:1 ( Plasma : RBC : Platelets ) ever be an adequate substitute for fresh whole blood, or should blood banks consider a return to using whole blood?
Tranexamic acid  should be consider and is significantly cheaper ( compare to Factor VII )

16. Giving unnecessary plasma and platelets should be discouraged in order to reduce the risk of transfusion-related acute lung injury
Poin of care  coagulation tests may aid decision making and reduce unnecessary transfusionst of care

17. Massive transfusion protocols, improve communication and delivery of blood products to the patient
Enable clinicians to give fresh plasma up front, rather than giving red blood cells initially and plasma later

18. How about Crystalloid ?
Giving a significant amount of crystalloid upfront on admission  a common practice  leading to various problem : Abdominal compartment syndrome ( ACS ), Acute Resp Distress Syndrome (ARDS ), multiple organ failure
Giving crystalloid > 1.5 liters in emergency department  independent risk factor for mortality > 70 years old  OR and Non elderly patients  OR 2.09
High volume ( > 3 liters )  > 70 years  OR 8.61,
Using Colloid  decreased lactate level and < renal injury  better tissue resuscitation

19. Fresh Whole Blood >> effective than Component
Transfusion Strategy
Masive transfusion : > 10 unit RBc within 24 hour
A significant advantage of Warm Fresh Whole Blood over component therapy  contain full amount of platelets
Even vs best practice  component therapy 1: 1:1
Fresh Whole Blood >> effective than Component

20. Damage control resuscitation (on admission)
Rapid control of surgical bleeding
Early and increased use of red blood cells, plasma and platelets in 1: 1: 1 ratio
Limitation of excessive crystaloid use
Prevention and treatment of hypothermia, hypocalcemia, and acidosis
Hypotensive resuscitation strategies
Sphan et al Critical Care 2013; 17:R76 – 1-45

21. Current recommendation for blunt trauma is to administer just enough fluid to maintain perfusion Rapid, high-volume fluid administration is discouraged Recommendation : Target BP systolic  80 – 90 mmHg, until major bleeding stop  afterwards optimalized In patients combined haemorragic shock and severe TBI (GCS < 8)  MAP > 80 mmHg

22. Permissive Hypotension in Traumatic Brain Injury
Oxygenation and Blood Pressure
Hypoxemia (<90% SpO2) and/or hypotension (<90 mm Hg systolic) are associated with poor outcomes.
Pulse oximetry and blood pressure must be monitored.
Continuous waveform capnography beneficial
CPP = MAP- ICP
Slightly higher systolic pressure may be required to maintain CPP in TBI

23. Target of Fluid Ressuscitation
DO2 = (CO x Hb x SpO2 x 1.34 ) + (PaO2 x 0,003) ↓ O2 Balance  O2ER= VO2 / DO2 = 25% VO2 = O2 Consumption

24. CONTROL CENTER IN THE MICROENVIRONMENT
Glycocalyx

25. Structure of Glyccocalyx
Glycocalyx
Endothelial cell
Reitsma S, et al. Eur J Physiol 2007; 454:345–359

26. Protect the Vessel Wall
ELECTRONE MICROGRAPH OF MYOCARDIAL CAPILLARY
Gouverneur M, Van den berg B, Nieuwdorp M, Stroes E, Vink H. Journal of Internal Medicine 2006; 259: 393–400

27. Alteration of Glycocalyx leads to extravasation
Alteration in the composition of the glycocalyx following exposure to an inflammatory insult is one of the earliest features of endothelial activation
It is now accepted that TNFα, oxidised lipoproteins, lipopolysaccharide, thrombin, ischaemia/reperfusion, hyperglycaemia and growth factors all cause glycocalyx disruption via the action of proteases
Hypervolemia ↓
Leads to disruption of the glycocalyx

28. Conclusion
First hour of trauma management  ABC’s  primary survey and secondary survey being accomplished as fast as possible
The time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control
Damage control resuscitation  on admission
Shock in trauma cases mostly hypovolemia  restore the iv volume
Fluid resuscitation  avoid further damage
Keep the blood pressure not to high before hemorrhage being controlled
Avoid hypervolemia
Target of resuscitation  balance between DO2 and VO2

29. Conclusions
Blood transfusion  Masive transfusion can be predicted ( BE -10 and Hb
Prefer to use WFWB  than blood component
Blood component  1 : 1 : 1
Use plasma first  to prevent traumatic coagulopathy

30. Terima Kasih