endpoints of resuscitation [in trauma]
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Endpoints of Resuscitation [in Trauma]
AJ Layon, MD, FACPProfessor and Chief
Critical Care Medicine
University of Florida College of Medicine
Gainesville, FL
Shock is imbalance of DO2 and VO2
• Resuscitation is complete when...– O2 debt is repaid
– Tissue acidosis is eliminated– Aerobic metabolism restored
Porter JM, Ivatury RR, J Trauma, 1998;44:908.
Severe Under-Resuscitation in Trauma is Shock
• …However we define this and with whatever monitors we use to determine endpoints
• ATLS Manual, 1993– An abnormality of the circulatory system that results in
inadequate organ perfusion and tissue oxygenation…
Lecture goals
• Cellular energetics during "acute illness"
• Systemic organ perfusion monitoring
• Selective organ perfusion monitoring / goals
• Old and new logistics of trauma
Organ Perfusion in Critically Ill Patients
TRAUMA
SIRSMOF
RECOVERYDEATH
O2 DEBT
Realistically, prevention of these is how we earn our salary
From the trauma bay to discharge from the ICU
Glycolysis (D-glucose to Lactate + 2H+) (energy)
ADP + ADP = ATP + AMP (vasodilatation)
CK reaction (PCr + ADP = H + ATP + Cr)
H+ + HCO3- CO2
free O2 radicals
NADH / NAD
cytosolic redox status
Lactate / pyruvate
1
2
3
4 5
limited to heart, brain, skeletal muscle
xanthine oxidase,
= H2O +
O2
Organ Perfusion in Trauma Patients
cellular parameters
Clinical parameters
Global and regional (organ perfusion) parameters
MTP: Class III and beyondEstimated Fluid and Blood Requirements1
(Based on Patient’s Initial Presentation)
Class I Class II Class III Class IV
Blood Loss (ml)Blood Loss (%BV)Pulse RateBlood PressurePulse Pressure (mm Hg)Capillary Refill TestRespiratory RateUrine Output (ml/hr)CNS-Mental Status
Fluid Replacement (3:1 Rule)
Up to 750up to 15%< 100NormalNormal or increasedNormal14 - 2030 or moreSlightly anxious
Crystalloid
750 - 150015 - 30%> 100NormalDecreased
Positive20 - 3020 - 30Mildly anxious
Crystalloid
1500 - 200030 - 40%> 120DecreasedDecreased
Positive30 - 405 - 15Anxious and confusedCrystalloid + blood
2000 or more40% or more140 or higherDecreasedDecreased
Positive> 35NegligibleConfused - lethargicCrystalloid + blood
1For a 70 - kg male
Class IV: 65% ofFactors and 75% Of Plts present
RL vs HTS: HTS wins
Murine hemorrhagic shock versusSham with LR versus Hypertonic SalineResuscitation: PMN activation
Murine hemorrhagic shock versusSham with LR versus Hypertonic SalineResuscitation: PMN activation
Deitch, Shock 2003;19:328Deitch, Shock 2003;19:328
Think TRALI/ARDS /
MOSF / ACS
Hemorrhage and Trauma
• New algorhythm in severe trauma:– Damage control resuscitation strategy– Focused on halting / preventing lethal triad:
• Coagulopathy• Acidosis• Hypothermia
Holcomb JB, et al. Ann Surg. 2008;248: 447 – 458
Old and New Paradigms
Carrico, et al. Transfusion Chapter in Mattox,
Moore and Feliciano
Cosgriff N, et al. Predicting life-threatening coagulopathy in the massively transfused patient:Hypothermia and acidosis revisited. J Trauma. 1997.
Coagulopathy: How Quick ?
• Loss of Coagulation factors– 1 Blood volume (BV) -
35% of factors remain– 2 BVs – 10% - 15%
remain– 3 BVs – 5% remain
• 20% - 30% of activity required for hemostasis
• Factors also consumed with clotting
• 1,088 Pts 1993 – 1998• Arrival to ED from scene ~ 73 min• 24% had coagulopathy (PT > 18, aPTT > 60 sec, TT >
15 sec) • Mortality for those with coagulopathy 46%
vs 11% in those without
Brohi K, et al: J Trauma, 2003;54:1127
Critical Revision of Old Trauma Trends
• Crystalloids are good for you– LR developed for diarrhea
• Fresh whole blood is bad for you• Plasma is a bad resuscitation fluid• Platelets should be given after the “surgical
bleeding” is controlled• Laboratory data are helpful in a rapidly bleeding
patient• RBCs today do not resemble those studied in the 70’s• No data in trauma as whole blood transitioned to
component therapy
ASA Guidelines on FFP Transfusion
• Blood usually coagulates appropriately when:– Coagulation factor concentrations are at least 20% - 30%
of normal – Fibrinogen is > 75 mg / dL
• Clinical coagulopathy from dilution does not occur until:– Replacement exceeds 1 BV or– PT / PTT exceeds 1.5 – 1.8 times control values
• With hypothermia1
– Coagulation enzyme reactions decreased by 10% / °C
1. Armand R, Hess JR: Treating Coagulopathy in Trauma Patients. Trans Med Rev, 2003;17 (3):223 – 231
Hemorrhagic Shock: MTP
• 80% to 85% of combat deaths not preventable– 66% to 80% of 15% to 20% of survivable combat-
related deaths result from hemorrhagic shock
• Recognition / treatment of coagulopathy important– Most Pts requiring MTP die within 6 hrs of admit
• Lethal triad after trauma:– Bleeding, hypothermia, acidosis
Borgman MA, et al. J Trauma. 2007;63:805–813
Mortality by Plasma : RBC Ration = 246 MT’s (2003 – 2005): Military
Borgman MA, et al. J Trauma. 2007;63:805–813
MT: Civilian
Holcomb JB, et al. Ann Surg. 2008;248: 447 – 458
466 / 1574 (29.6%) civilian trauma Pts retrospective analysis of registries
No ISS / AIS differences. Overall survival 59%Range by center: 41% - 74%
Mortality vs mean FFP / RBC ratio byCenter and Variability: Civilian
Holcomb JB, et al. Ann Surg. 2008;248: 447 – 458Massive transfusion practice guidelines should aim for a 1 : 1 : 1 ratio of FFP : Plts : PRBC
RISKS OF FFP and PLATELETS
• Reports of TRALI from the UK haemovigilance program– Suggest risk from FFP ~ 1 in 50,000 to 60,000 units– May now be the commonest cause of death from transfusion– Is the most frequent serious complication of FFP
• In most of the TRALI cases arising from FFP– Female donors identified as the source of the antibodies– ARC recently limited female donors
• Further lowering risk of a rare complication
Eder AF, et al. Transfusion, 2010;50:1732-1742Wiersum – Osselton JC, et al. Transfusion, doi: 10.1111/j 1537-2995.2010.02969.x [4 April, 2011]Rios JA, et al. Transfusion, doi: 10.1111/j.1537-2995.2010.02991.x [11 April, 2011]
Resuscitation Endpoints
• Historical– BP, HR, UOP– However...
• 80% - 85% under-resuscitated when values normalized– Elevated lactate– Decreased SVO2
Scalea et al, CCM, 1994;22:1610.Abou-Khalil et al, CCM, 1994;22:633.
BP and Coronary Autoregulation
Bellomo et al. Critical Care 2001;5:294
10 30 50 70 90 110 1300
20
40
60
80
100
120
Flo
w (
% o
f n
orm
al)
Perfusion pressure (mm Hg)
Heart Hypertrophicheart
0 25 50 75 100 125 1500
25
50
75
100
Mean Arterial Blood Pressure (mm Hg)
Cer
ebra
l Blo
od F
low
(c
c/10
g/m
in)
50 mm Hg 80 mm Hg
Normal autoregulation
Disrupted autoregulationAB
Zone of NormalAutoregulation
Blood Pressure (MAP) is Brain Flow
65
Range of Hyperfusion
Additional Endpoints of Resuscitation
• Oxygen delivery• SvO2 and ScvO2
• Arterial base deficit• Arterial lactate• Gastric tonometry……….• Near Infrared Spectroscopy (NIRS)• Physical examination
• DO2 = Q X CaO2 = Q X [(Hb x 1.39 x SaO2) + 0.003 x PaO2)]
For a CO = 5 and Hb = 15: • DO2 = 1000 mL / min or 620 mL / min / m2
• VO2 = Q X (CaO2 - CvO2) = 240 mL / min or 170 mL / min / m2
• O2ER = (CaO2 - CvO2) / CaO2 = 0.27%............or
(SaO2 - SvO2) / SaO2
Back to basicsOrgan Perfusion in Critically Ill Patients
(Valid for Everyone)
Cytopathic Tissue Hypoxia in Critical Illness is Proportional to SVO2 (& CI)
Mixed venous oxygen saturation (SvO2 ) and mitochondrial respiration measured as mitochondrial-dependent reduction of WST-1 (abs, absorbance) for 15 patients with septic shock
Rs = .61
P < 0.05
Roulos M. Crit Care Med. 2003 Feb;31:353 – 8
Shoemaker WC, et al. Chest. 1992;102:208 – 215
And in fact Net Cumulative VO2 Deficit is much more for Non Survivors.
Then a number of ER guys showed some magic
49.2%
33.3%
0
10
20
30
40
50
60
Standard Therapy N = 133
EGDTN = 130
P = 0.01 *
Rivers E, et al. N Engl J Med. 2001;345:1368 – 1377
Rivers Protocol: EARLY GOAL (SsvcO2 > 70%)
Cardiac Filling Pressures: Not Appropriate to Predict Response to Volume Challenge
Osman D,et al. Crit Care Med. 2007;35:64 – 68
Interpretation of an Elevated PAOP (20)
A. High extracardiac pressure with normal preload
B. Normal extracardiac pressure and increased preload in a normally compliant ventricle
C. Normal / decreased preload of a poorly compliant ventricle
Scattergram of cardiac index (Cl) vs pulmonary artery wedge pressure (PAWP) with first-order regression line of best fit (Cl = 3.103 + 0.098 x PAWP) (n = 131,
r = .418, P < .001)
Scattergram of cardiac index (Cl) vs right ventricular end-diastolic volume index (RVEDVI) with first-order regression line of best fit (Cl = 1.094 + 0.028 x RVEDVI) (n =
131, r = .613, P < .001)
Baseline ΔPP Predicts Volume Responsiveness in Hypotensive Critically
Ill Patients
Michard F, et al. Am J Resp Crit Care Med. 2000;162:134 – 138
50
40
30
20
10
0
y = 1.01x – 1.46r2 = 0.85
0 10 20 30 40 50
Ch
ange
s in
car
diac
inde
x (%
)
Baseline ΔPP (%)
Baseline ΔPP Predicts Volume Responsiveness in Hypotensive Critically Ill Patients
Michard F, et al. Am J Resp Crit Care Med.2000;162:134 – 138
Bakker Chest 1991;99:956-62Ngyen Crit Care Med 2004;32:1637-42
Persistent Lactic Acidosis = Decreased Survival
DO2 VO2 Lactic Acid
*
Mortality
Number of Pts
500
400
300
200
100
00 -5 -10 -15 -20 -25 -30 -35 -40 -45
0
20
40
60
80
100
BASE DEFICIT (mmol/L)
PATIENTS
%
MORTALITY
Rutherford et al, J Trauma, 1992;33:417.Rutherford et al, J Trauma, 1992;33:417.
Increased BD = Decreased Survival
BE vs MOSF Post Trauma
0
5
10
15
20
25
30
35
40
BE<=4
BE > 4
% MOSF
Kincaid, J Am Coll Surg, 1998;187:384 – 392
*
* p < 0.001
Organ Perfusion in Critically Ill Patients
Persistent Base Deficit = Decreased Survival
0 1 2 3 4 5
-13
-12
-11
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
4
Days after admission
Sta
nd
ard
bas
e ex
cess
(m
Eq
/L)
Survivors
Non survivors
#
#
* #
Park M, et al. Evolutive standard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal directed therapy: Still outcome markers ? Clinics. 2006;61:47 – 52
CO2 freely diffuses in tissuesPCO2 in the balloon is in equilibrium with mucosal PCO2
Arterial HCO3- = mucosal HCO3
-
pHi = 6.1 + (log [HCO3-] / mucosal PCO2)
pHi - pHa gap PtCO2 - PaCO2 gap
Gastric Tonometry
Organ Perfusion in Critically Ill Patients
2COCO2
2COCO22COCO2
2COCO22COCO22COCO2
Gastric tonometry is based on the principle that tissue production of CO2 rises sharply with tissue dysoxia.
Weil CCM 1999 Vol 27 (7): 1225-29
Organ Perfusion in Critically Ill PatientsSublingual Capnometer
1) accessible2) high PC stores
Sublingual PCO2 (PSLCO2)
Marik PE. Chest 2001;120:923-927
Povoas H, et al. Chest 2000;118:1127-1132
†Weil MH, et al. Crit Care Med. 1999; 27:1225-1229
30
mmHg
15070
Orthogonal Polarization Spectral Imaging: Sublingual Circulation
- Normal
De Backer Daniel, et al. Am J Resp Crit Care Med. 2002;166:98 – 104
- Sepsis - Hypoperfusion
Orthogonal Polarization Spectral Imaging: Sublingual Circulation
De Backer Daniel, et al. Am J Resp Crit Care Med. 2002;166:98 – 104
OPS Imaging: Sublingual Circulation
Creteur J, et al. Intensive Care Med. 2006;32:51–523
• 18 consecutive MV Pts in early phase (within 24 h) of septic shock, defined as:• Hypotension (MAP < 65 mmHg) requiring a pressor agent
• Dopamine > 5 μg/kg/min or NE• In the presence of an infection
• Pts treated with midazolam, morphine, H2 receptor blocker
Near-Infrared Spectroscopy(NIRS)
• Continuous, noninvasive tissue oxygen monitor
Lima AP. Int Care Med. 2005;31:1316 – 1326
Cuff released
Baseline
Co
nce
ntr
atio
n c
han
ges
(m
M)
Arterial oclusion
NIR-lightDetection
ProbeNIR-lightEmission Probe
Near-Infrared Spectroscopy: NIRS
• Uses light transmission and absorption to measure concentration of Hb, StO2 and cyt-aa3 in tissue
• Global assessment of oxygenation in arterial, venous and capillary compartments– Limitation
• Affected by edema– Application
• Brain• Skeletal muscle and visceral ischemia
Regional Perfusion Markers
• McKinley et. al., 2000• Severely injured trauma
patients
Found the measurementof tissue oxygenationcorrelated well withoxygen delivery, basedeficit and lactate levels.
StO2 (20 mm; skeletal muscle)
StO2 (6 mm; subcutaneous)
DO2I
1009080
70
60504030
2010
0
800
1000
600
400
200
0
StO
2 (
%)
PgCO2
PgCO2 – PaCO2gap
80
70
60
50
40
30
20
200
Pg
CO
2, g
ap (
mm
Hg
)
SvO2
BD
lactate
01020
30
4050
6070
80
90S
vO2 (
%)
0 4 8 12 16 20 24 28 32 36-2
0
2
4
6
8
BD
(m
Eq
/L),
la
cta
te (
mM
)
TIME (hr)endresuscitation
start
End Point of Resuscitation in Trauma: Conclusions
• This was a Troglodytic field– Now better– No ABC, no fast surgeon, no mission accomplished
• Non-crystalloids resuscitation is the new buzz – PRBC / FFP / Plts / Cryoprecitate
• BP / Pulse / UOP / MS practical but not accurate• At some point DO2 / VO2 relationship needs to be evaluated
and corrected if feasible• Biomarkers are very reasonable endpoints, as long as
sampled frequently • Fancy toys coming………..stay tuned
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