05-Sibylle Kozek-Langenecker

1. Towards the perfect fluid strategy:
Fluid strategy in hemorrhagic shock
Sibylle A. Kozek-Langenecker
Evangelic Hospital Vienna
www.perioperativebleeding.org
sibylle.kozek@aon.at

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

3. 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

4. Na+
K+
K+
Na+
intravascular interstitial intracellular
Na+
K+
proteinprotein
water water
proteinprotein
Physiological basics

5. Physiological basics
mod. Jacob 2012

6. 45 litres

7. intracellular
space
30 litres

8. 15 litres
extracellular
space

9. 12 litres
interstitial
space

10. 3 litres
intravascular
space

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

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

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

14. pure water
Pharmacodynamics

15. isotonic crystalloid
Pharmacodynamics

16. urine output
extravascular deficits
insensible perspiration
evaporation
Fluid substitution
Lamke. Acta Chir Scand 1977; 143: 279-84
Jacob M, Chappell D, Rehm M. Lancet 2007; 369: 1984-6
0.5-1 ml/kg/h

17. Excessive crystalloid
substitution
Jacob. Anaesthesist 2007, 56:747-64
Hypervolemia

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

19. isooncotic colloid
Pharmacodynamics

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

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

22. Context-sensitivity of
volume efficacy
in hemorrhagic shock:
highest volume efficacy
Jacob. Lancet 2007, 369: 1984-6

23. Context-sensitivity on the
cover

24. 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

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

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

27. 1:1:1 ratio concept: á 600 ml
500 mL500 mL
Hct: 38-45%Hct: 38-45%
Plt: 150-Plt: 150-
400K400K
Coags:Coags:
100%100%
PRBCPRBC
Hct 55%Hct 55%
335 mL335 mL
PltPlt
5.5x105.5x101010
50 mL50 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 ?

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

29. Dosing of fluids
target parameters & safety aspects

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

31. 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

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

33. Colloidal patient safety issues
overload
endothelial damage
intraabdominal hypertension
dose of colloid
„therapeutic window“
inadequatevolumetherapy
death
anaphylaxis
coagulopathy & bleeding
kidney dysfunction
itching
adverseoutcomes

34. Colloidal safety measures
individualized dosing
IA pressure monitoring
?
dose of colloid
„therapeutic window“
fluidmonitoringand
individualiseddosing
anamnesis, awareness & symptomatic treatment
Choice of colloid
avoidanceofadverseoutcomes

35. 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

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

37. Haas. Anesth Analg 2008;106:1078
30 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
MCF blood loss
HS-HES 11 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 = 0.0034 p =0.004
Small volume resuscitation

38. Small volume resuscitation &
outcome
shock + blunt/penetrating trauma:
no difference in mortality BUT
increased mortality in subgroup without RBCs
Bulger EM. JAMA. 2010; 304:1455-64
shock + traumatic brain injury:
no difference in mortality and neurological outcome
Cooper D. JAMA 2004; 291;1350-1357

39. 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

40. FRACTA 2013
February 7th
-9th
2013 in Prague
safe the date
sybille.richter@fresenius-kabi.com

41. www.perioperativebleeding.org
sibylle.kozek@aon.at
Thank you for your attention !