frederick a. moore md november 8, 2012 resuscitation beyond the abdominal compartment syndrome (acs)

Frederick A. Moore MD

November 8, 2012

Resuscitation Beyond the

Abdominal Compartment Syndrome (ACS)

1)Discuss 4 advances in trauma care that occurred in the 1980s that caused an epidemic of ACS in 1990s.

2) Discuss implementing and studying a ICU resuscitation protocol that helped us recognize that ACS is iatrogenic.

3) Discuss fundamental changes in early management of patients who arrive with severe bleeding to eliminate ACS.

Objectives

Advances in Trauma Care in 1980s

Epidemic of ACS in the mid 1990s

Trauma System Development

Advanced Trauma Life Support

Damage Control Surgery

Goal Oriented Resuscitation







High Volume Trauma Centers with Shock Trauma ICU







Early High Volume Isotonic Crystalloid Resuscitation to Achieve Normal Blood Pressure as Standard of Care







Severely injured patients do not bleed to death in OR






Goal Oriented ICU Resuscitation









Problematic gut edema in the nonresponders

Memorial Hermann Hospital UT Houston Med School

Moved to Houston in December 1995

Memorial Hermann Hospital UT Houston Medical School

LIFE FLIGHTFOUNDED IN 1976

Dr James H “Red” Duke Jr

BLUNT TRAUMA PLUS SHOCK

A Decision Making Conundrum

LDS Hospital Salt Lake City, Utah

Alan Morris MD Tom East PhD

LDS Hospital Salt Lake City, Utah

Computerized Clinical Decision Support (CCDS) For Mech Vent Of ARDS

“Significant problems we face cannot be solved at the same level of thinking we were at when we created them.”

Albert Einstein

Bruce McKinley

J Trauma 2002

Matt Sailors

J Trauma 2002

Bioengineer Informatics Expert

J Trauma 2001J Trauma 2001J Trauma 2001

Bedside Algorithm

DENVER GENERAL HOSPITAL

Crit Care Med 1988

William Shoemaker

Berfauk 1991 Peri-Op Surg Yes

Fleming 1992 Trauma Yes

Tuchschmidt 1992 Septic Shock ? Yes

Yu 1993 Sick ICU No

Boyd 1993 Peri-Op Surg Yes

Hayes 1994 Sick ICU No

Durham 1995 Trauma No

Gattinoni 1995 Med ICU No

Yu 1998 Surg > 50 yrs Yes

PRCT’s TESTING “ SUPRANORMAL DO2 ” RESUSCITATION DOES IT REDUCE MORTALITY?

DO2

goal

1) Hb (PRBC; Hb 10 )

2) volume (LR; PCWP >15 )

3) Optimize CI - PCWP(Starling curve)

4) low dose Inotropes 5) vasopressor

Yes No

Yes

No

Met inclusion criteria

On ICU admission:art, PA, NG tonometer catheters

baseline ABG, Hb, lactate

24 hours?24 hours?

Echocardiographystop resuscitationstandard ICU carestop resuscitationstandard ICU care

lactate, BD, PrCO2

bladder pressureQ 4h (reassess sooner if

abnormal)

Monitor:

Q 4h (reassess sooner if abnormal)

> 600

Started 1997 DG MOF Database

1.1. Iterative processIterative process2.2. Evaluation / testing at each stepEvaluation / testing at each step3.3. Never “done” – always monitoring / refiningNever “done” – always monitoring / refining

ICU Shock Resuscitation

Me Algorithms Matt

J Trauma 2002J Trauma 2002

COMPUTER DIRECTED RESUSCITATION OF MAJORTORSO TRAUMA

Bruce A. McKinley, R. Matthew Sailors, Christine S. Coconour, Alicia ValdiviaRosemary M. Kozar, and Frederick A. Moore

Standard of Care in 1999


PROSPECTIVELY COLLECT DATA

HOW PATIENTS RESPOND TO INTERVENTIONS


ONGOING DATA ANALYSIS

REFINEMENTS IN THE PROTOCOL

Ann Surg Sept 2000

Mm

George Velmahos

Los Angeles County

Ann Surg Sept 2000

DO2

goal

1) Hb (PRBC; Hb 10 )

2) volume (LR; PCWP > 15 )

3) Optimize CI- PCWP(Starling curve)

4) low dose Inotropes 5) vasopressor

Yes No

Yes

No

Met inclusion criteria

On ICU admission:art, PA, NG tonometer catheters

baseline ABG, Hb, lactate

24 hours?

Echocardiography

lactate, BD, PrCO2bladder pressureQ 4h (reassess sooner if abnormal)

Monitor:

Q 4h (reassess sooner if abnormal)

> 500

Computerized Protocol

stop resuscitationstandard ICU care

Changed DO2 goal

January 2001

STANDARD OF CARE

Field / ED / OR / IR Suite ATLS

“ Damage Control ” surgery

Early triage to the ICU

Optimize systemic perfusion

SAVES LIVES

Jim Cross

ABDOMINAL COMPARTMENT SYNDROME

Open abdomens

Organ failure

Prolonged ICU stays

Field / ED / OR / IR Suite ATLS

“ Damage Control ” surgery

Early triage to the ICU

Optimize systemic perfusion

SAVES LIVES – BUT ???????

STANDARD OF CARE

PRIMARY ACS ASSOCIATED ABDOMINAL INJURIES

Case Reports in the 1980s


Case Reports in the 1980s

Recognized Entity by mid 1990s

Patient Type Incidence Mortality

Morris

1993

Damage Control 15% 63%

Hirshberg

1994


Meldrum

1997

E-Lap

ICU Admit

14% 30%

Ivatury

1998

Penetrating Severe, E-Lap

32% 44%

Raeburn

2001



Case Reports in the late 1990s

SECONDARY ACSNO ABDOMINAL INJURIES

Case Reports in the late 1990s

Recognized Entity by early 2000s


N ISS Mortality (%) UBP (mmHg)

Hours to decompression

Lived Died

Maxwell

1999

6 25 67 33 3 25 *

Kopelman

2000

6 17 67 31 48 192 *

Biffl

2001

14 NA 38 30 12 5

Balogh

2002

11 28 54 34 14 10

CASE SERIES


Shock 2003

Zsolt Balogh

Visiting Research Fellow

Hungarian Trauma Surgeon

Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation

Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D.

Am J Surg 2002


#2

Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., John B. Holcomb, M.D., Charles C. Miller, Ph.D.,Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, RN Drue N. Ware, M.D. and Frederick A. Moore, M.D. J Trauma 2002

J Trauma 2003J Trauma 2002J Trauma 2002

# 3

Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Charles C. Cox, M.D.and Frederick A. Moore, M.D.

Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., John B. Holcomb, M.D., Charles C. Miller, Ph.D.,Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, RN Drue N. Ware, M.D. and Frederick A. Moore, M.D.

# 3

#2

Am J Surg 2003

152 Resuscitation Protocol Patients

85 Patient16 months ending Jan 2001 DO2I Goal > 600

71 Patient16 months after Jan 2001 DO2I Goal > 500

# 4

Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, R.N. R. Mathew Sailors, B.S.,Frederick A. Moore, M.D.

Arch Surg 2003

GroupAge

(years)Male (%)

ISS BD (mEq/L)

Pre-ICU

LR (L)

Pre-ICUPRBC

(U)

DO2I600 37 ±3 76 28 ±3 9 ±1 6 ±1 5 ±1

DO2I500 33 ±2 74 27 ±2 9 ±1 5 ±1 5 ±1

GROUPS WERE SIMILAR PRIOR TO ICU ADMIT

Cardiac Index during ICU resuscitation

2.5

3

3.5

4

4.5

5

5.5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Time (hours)

Car

diac

Inde

x (m

L/m

in/m

2)

DO2I>600DO2I>500

Base Deficit During ICU Resuscitation

-1

0

1

2

3

4

5

6

7

8

1 5 9 13 17 21 25Time (hours)

Bas

e D

efic

it (m

Eq/

L)

DO2I>600

DO2I>500

P = 0.07

SvO2 During ICU Resuscitation

70

71

72

73

74

75

76

77

78

79

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Time (hours)

SvO

2 (%

)

DO2I>600

DO2I>500

Serum Lactate Concentration

1.5

2.5

3.5

4.5

5.5

6.5

1 5 9 13 17 21 25Time (hours)

Ser

um

Lac

tate

(mm

ol/L

) DO2I>600

DO2I>500

CARDIAC INDEX

BASE DEFICIT

SvO2

LACTATE

Lactated Ringer's Infusions

0

2

4

6

8

10

12

14

16

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Time (hours)

Lact

ated

Rin

ger's

(Lite

rs)

DO2I>600

DO2I>500

Packed Red Blood Cell Transfusions

0

1

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Time (hours)P

RB

C (U

nits

)

DO2I>600

DO2I>500

P < 0.05 P = 0.07

Group IAH % ACS % MOF % Death %

DO2I600 42 * 16 * 22 * 27 *

DO2I500 20 8 9 11

* p< 0.05IAH = UBP > 20 mm Hg

Shock 2003



Am J Surg 2002

Shock 2003

Epidemiology of Primary and Secondary ACS

Surprizingly Early Decompressive Lap ~ 12 hrs

Accurately Predict within 3 hrs after ED Arrival

Strongly Associated with MOF and Death

Shock 2003



Am J Surg 2002

Shock 2003

ACS and ICU Resuscitation Protocol

Impending ACS patients are non-responders

Decreasing D02 goal decreased ACS, MOF & Death

Shock 2003



Am J Surg 2002

Shock 2003

ACS is not an ICU resuscitation problem

It starts in the ED in patients arriving with severe bleeding

Fundamental changes in early care of these patients

FUNDAMENDAL CHANGE IN PRE - ICU CARE OF PATIENTS ARRIVING WITH SEVERE BLEEDING

ED Resuscitation Massive Transfusion

Whole Body CT Scanning

FAST with backup Diagnostic Peritoneal Aspirate

Pelvic Fracture




Pelvic Fracture


ED RESUSCITATION

Stabilize

BP < 90 mmHgor

BD ≥ 6 mEq/L

Place Central Line

CVP < 10 CVP > 15

? Cardiogenic Shock

Inflammation and the Host Response to Injury, a Large-Scale Collaborative Project:Patient-Oriented Research Core - Standard Operating Procedures for Clinical Care

III. Guidelines for Shock Resuscitation

Frederick A. Moore, MD, Bruce A. McKinley, PhD, Ernest E. Moore, MD, Avery B. Nathens, MD, PhD, MPH,Michael West, MD, PhD, Michael B. Shapiro, MD, Paul Bankey, MD, PhD, Bradley Freeman, MD,Brian G. Harbrecht, MD, Jeffrey L. Johnson, MD, Joseph P. Minei, MD, and Ronald V. Maier, MD

Surgical Glue Grant

J Trauma 2006

Evidence Based ED Shock Algorithm

ED RESUSCITATION

Traumatic Shock ATLS – volume load

Arterial Blood Gas

Stabilize

Place Central Line

CVP < 10 CVP > 15

Resuscitate until stableor

[Hb] ≥ 10 & CVP ≥ 10

? Cardiogenic Shock

ED RESUSCITATION

Traumatic Shock ATLS

ABG

Stabilize

Systolic Blood Pressure < 90 mmHgor

Base Deficit ≥ 6 mEq/L

CVP < 10 CVP > 15


[Hb] ≥ 10 & CVP ≥ 10

? Cardiogenic Shock

ED RESUSCITATION


ABG

Stabilize

SBP < 90 mmHgor

BD ≥ 6 mEq/L

Place Central Line

CVP < 10 CVP > 15


[Hb] ≥ 10 & CVP ≥ 10

? Cardiogenic Shock

ED RESUSCITATION


ABG

Stabilize

SBP < 90 mmHgor

BD ≥ 6 mEq/L

Place Central Line

CVP < 10 CVP > 15


[Hb] ≥ 10 & CVP ≥ 10

? Cardiogenic Shock

“Waffle”

NEJM 1994

Ken Mattox

HYPOTENSIVE RESUSCITATION

Standard of Care for

Penetrating Torso Trauma

598 PatientsPenetrating Torso Trauma Field SBP < 90 mm Hg

309 ImmediateResuscitation

298 DelayedResuscitation

62 %Survival

70 %Survival

*

* p < 0.05

NEJM 1994

BLUNT TRAUMA plus SHOCK

? Hypotensive Resuscitation

NEJM 1994

More Complex Clinical Decisions

CPP Secondary Brain Injury

Volume Loading Defines Stability



NEJM 1994




20% have associated Head Injury – very bad outcomes



NEJM 1994




This drives early triage decisions



NEJM 1994




SBP > 90 mm Hg and HR < 13O until Hemorrhage Control

Permissive Hypotension



FAST with backup Diagnostiic Peritoneal Aspirate

Pelvic Fracture


0 4 8 12 16 20 24Time ( hrs after ICU Admission)

John Holcomb

Massive Transfusion Protocol

ED, OR & IR suite

Empiric replacement

ICU Protocol

Lab test driven

Recombinant Factor VIIa Protocol

Rescue therapy

Fill out approval form

Call Keith Hoots, M.D.

Treatment of Postinjury Coagulopathy

Critical Care Fellow

MASSIVE TRANSFUSION PROTOCOLStart After 6 units of PRBCs

Attending/Fellow notifies Blood BankCall 4-3640

Send runner to pick up cooler6 Units PRBC’s6 Units FFP

Blood Bank will replace coolers6 Units PRBC’s6 Units FFP

6 Pack of platelets every 12 units PRBC’sWhen patient arrives in ICU Blood Bank stops the protocol

ICU PROTOCOL


Ernest Gonzalez

Critical Care Fellow

T-32 Research Fellow

Became Trauma Attending

Inherited Massive Transfusion Protocol

Sent to us by John Holcomb

Prothrombin time, Int'l Normalized Ratio

12

14

16

0 4 8 12 16 20 24

PT

(s

ec

)

1.2

1.3

1.4

1.5

1.6

INR

PT v timeINR


23 ( 11 % ) had ICU admission PT > 18 sec

23 ( 12 % ) had PT > 18 sec

HOW ARE WE DOING ?

Resuscitation Protocol Shock

J Trauma 2006

Lactated Ringers 9 ± 1 liters

PRBC 11 ± 1units

FFP 5 ± 0.4 units

100 % Hemorrhage Control Interventions

94 Emergency operations

16 Interventional radiology embolizations

Arrived in STICU 6.8 ± 0.3 hrs after ED admit

97 Massive Transfusion Patients Pre-ICU Resuscitation

6 unit difference by design

Lactated Ringers 9 ± 1 liters

PRBC 11 ± 1units

FFP 5 ± 0.4 units

100 % Hemorrhage Control Interventions

94 Emergency operations

16 Interventional radiology embolizations

Arrived in STICU 6.8 ± 0.3 hrs after ED

97 Massive Transfusion Patients Pre-ICU Resuscitation

6 unit difference by design

Too much

Too long

Int'l Normalized Ratio, PRBC transfusion

1.2

1.4

1.6

0 4 8 12 16 20 24ICU TIME (hr)

INR

0

2

4

6

8

10

12

PR

BC

(uni

t)

INR

PRBC

ICU Resuscitation Protocol

Cumulative PRBC/FFP Volumes 1st 24 hrs of STICU Resuscitation

Cumulative PRBC, FFP Volumes

0

4

8

12

0 4 8 12 16 20 24

ICU TIME (hr)

PR

BC

, FFP

(un

it)

PRBC

FFP

9 ± 1 Units PRBC9 ± 1 Units FFP

INR on ICU admission vs Mortality

ICU Admission BD = 6.6 ± 0.5

Early ICU INR vsProbability of Death

0

0.2

0.4

0.6

0.8

1

1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.5 2.7

INR

pro

ba

bilit

y p=0.02P = 0.02, ROC = 0.71

Patients who arrive in the ICU with a coagulopathy die


12

14

16

0 4 8 12 16 20 24

PT

(s

ec

)

1.2

1.3

1.4

1.5

1.6

INR

PT v timeINR



23 ( 12 % ) had PT > 18 sec

Start MTP as soon as the need can be identified

Do not wait until 6 units PRBCs

Give fresh thawed plasma with 1st unit PRBC

Maintain units of FFP:PRBC ratio at 1:1

Limit crystalloids

Focus on hemorrhage control

J Trauma 2006


12

14

16

0 4 8 12 16 20 24

PT

(s

ec

)

1.2

1.3

1.4

1.5

1.6

INR

PT v timeINR



23 ( 12 % ) had PT > 18 sec

Start MTP as soon as the need can be identified

Give fresh thawed plasma with 1st unit PRBC

Maintain units of FFP:PRBC ratio at 1:1

Limit crystalloids

Focus on hemorrhage control

J Trauma 2006

Follow-up StudyPost 1:1 FFP to PRBC Protocol

95 Patients over 24 Months ending June 07

Age = 37 ± 2 , 73.6% Male Gender

ISS = 28 ± 1 , 69 % Blunt Mechanism

ED Base Deficit = 9 ± 0.6 , ED INR = 1.6 ± 0.1 85 % Survival , ICU Stay = 17 ± 2 days

Presentation at 2008 Western Trauma Association

192 MT Patients

Age 39±2 37±1.6 0.44

ISS 29±1 28±1 0.53

ED BD 10±0 9±0.6 0.67

ED INR 1.8±0.2 1.6±0.08 0.41

97Pre 1:1

P value 95Post 1:1

Follow-up Study

192 MT Patients

97Pre 1:1

95Post 1:1 P value

Pre-ICU Cryst (L) 9±1 6±0.4 0.07

Pre-ICU PRBC 12±1 15±1.2 0.06

Pre-ICU FFP 5±0.4 11±1.0 <0.05

Hrs ED to ICU admit 6.8 ± 0.3 4.4 ± 0.2 <0.05

Follow-up Study

192 MT Patients

97Pre 1:1

P value

ICU admit 35.4 ± 0.1 36.5 ± 0.1 <0.001 Temp

ICU admit 7 ± 1 5 ± 1 0.16 BD (mEq/L)

ICU Admit 1.6±0.04 1.4±0.03 0.02 INR

Mortality 30 % 15 % 0.02

95Post 1:1

Follow-up Study




Pelvic Fracture

FUNDAMENDAL CHANGE IN PRE - ICU CARE OF PATIENTS ARRIVING WITH SEVERELY BLEEDING


ATLS Volume Challenge

Unstable Stable

Operating Room Whole Body CT Scan

Critical Triage Decision



Unstable Stable


Do You Have 30 mins?

Know All Serious Injuries



Unstable Stable


If you don’t have 30 mins !Your Chance to Save a Life

CRUCIAL TRIAGE DECISION


Unstable Stable

Base Deficit

StO2

CVP

Age

Obvious Injuries

CT Scan AvailabilityOperating Room CT Scan

Focused Assessment for Sonography in Trauma Patients

4 Views

Right Upper Quadrant

Pericardial Area

Left Upper Quadrant

Suprapubic Area

FAST Exam has Replaced DPL

FAST: USA Series

Year # Patients Sensitivity Specificity

Rozychi 1995 371 82% 99%

Healy 1996 796 89% 98%

McKinley 1996 1000 88% 99%

Thomas 1997 300 81% 99%

Dolich 2000 2500 86% 98%

FAST: Experts Performance

Year # Patients Sensitivity Specificity

Rozychi 1995 371 82% 99%

Healy 1996 796 89% 98%

McKinley 1996 1000 88% 99%

Thomas 1997 300 81% 99%

Dolich 2000 2500 86% 98%

Positive FAST - very valuable for triage decisions

Negative FAST - does not rule out intra-abdominal bleeding

Backup Diagnostic Peritoneal Aspirate (DPA)




Pelvic Fracture


Typical Friday Night Case

39 yr old male, high speed MCC

Intubated, field SBP < 90, 1.5 liter LR

1 hr from time of injury to trauma center arrival

On arrival SBP = 84 , HR = 120

Responded to a fluid bolus

39 yr old male, high speed MCC

Intubated, field SBP < 90, 1.5 liter LR

1 hr from time of injury to trauma center arrival

On arrival SBP = 84 , HR = 120

Responded to a fluid bolus

Typical Friday Night Case

SBP = 108 & HR = 110 [Hb] = 10.7 gm/dl Base deficit = 9 mEq/L INR = 1.6 , FAST negative

After 20 minutes

RESUSCITATION PROTOCOL

MassiveTransfusion Policy

FAST/DPL

+_

Unstable Stable

OR Whole Body CT Scan

Unstable Pelvic Fracture

Central Line

Open Booked Vertical Shear

Unstable Pelvic Fracture MassiveTransfusion ProtocolWrap Pelvis

FAST/DPL

+_

Unstable Stable


Limit Crystalloids


RESUSCITATION PROTOCOL Central Line

PELVIC FRACTURE plus SHOCK

“Play Cards” Quickly

Pack Pelvis & do an Exploratory Laparotomy

30% Spleen/Liver/Mesenteric Bleeding

Angiography

Radiology Consult

External Fixation

Orthopedic Consult

Unstable Pelvic FractureWrap Pelvis

FAST/DPA

+_

Unstable Stable


MassiveTransfusion Protocol


Limit Crystalloids



FAST/DPA

+_

Unstable Stable

OR Pack PelvisLaparotomy

Angio

Shock Trauma ICU

OR FixationIf Appropriate



Limit Crystalloids


J Trauma 2005

Gene Moore

J Trauma 2005


FAST/DPA

+_

Unstable Stable

Whole Body CT Scan

Angio PelvicBlush

Shock Trauma ICU

OR FixationIf Appropriate


Limit Crystalloids

Hypotensive Resuscitation


“ The connection between cause and effect

has no beginning and can have no end “

Leo Tolstoy

War and Peace





ADVANCES IN TRAUMA CARE

Saved Patients Who Used to Bleed to Death in OR

ADVANCES IN TRAUMA CARE

EPIDEMIC ABDOMINAL COMPARTMENT SYNDROME


Am J Surg 2003

Shock 2003

By implementing & studying an ICU resuscitation protocol

ACS starts in the ED in patients arriving with severe bleeding


has largely eliminated this iatrogenic complication!

SHOCK 2003


Am J Surg 2003

Shock 2003

By implementing & studying an ICU resuscitation protocol

ACS starts in the ED in patients arriving with severe bleeding


has largely eliminated this iatrogenic complication!

2010’ s: What will kill next generation of trauma patients ?

SHOCK 2003

Rosemary Kozar

John Holcomb

Trey Miller Zsolt Balogh

Chris Cocanour

Ernest GonzalezNeel Ware Chuck Cox

frederick a. moore md november 8, 2012 resuscitation beyond the abdominal compartment syndrome (acs)

Documents

trauma care

s epidemic of acs

shock trauma icu advances

matt sailors j trauma

standard of care advances

icu resuscitation protocol

objectives advances

volume lr pcwp