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Trauma: Choice of fluids
1. Trauma:
Choice of fluids
Sibylle A. Kozek-Langenecker M.D. Professor MBA
Department of Anaesthesia and Intensive Care
Evangelical Hospital Vienna
www.perioperativebleeding.org
sibylle.kozek@aon.at
2. Honoraria for lectures and travel reimbursement:
B. Braun
Fresenius Kabi
CSL Behring
Conflicts of interest
3. isotonic saline
hypertonic saline
buffered crystalloid
e.g. Ringer lactate, acetate
hypooncotic colloids
e.g. gelatin, 4 or 5% albumin
hyperoncotic colloids
e.g. HES, 20 or 25% albumin, dextranes
allogeneic blood products
no fluids
Available solutions
7. 1:1:1 = haemodilution
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
á 600 ml
8. Massive transfusion protocols
(MTP)
Riskin D. J Am Coll Surg 2009: 209; 198
• mortality decreased with MTP introduction from
49% to 19%
• speed of therapy vs. product ratio
9. Riskin D. J Am Coll Surg 2009: 209; 198
Riskin D. J Am Coll Surg 2009: 209; 198
Similar FFP:RBC ratio
before and after MTP implementation
Riskin D. J Am Coll Surg 2009: 209; 198
10. Riskin D. J Am Coll Surg 2009: 209; 198
Riskin D. J Am Coll Surg 2009: 209; 198
De Biasi A. Transfusion 2011: 51; 1925
Increased speed of therapy
determines survival
Riskin D. J Am Coll Surg 2009: 209; 198
11. Indications for plasma
• correction of hereditary deficiencies in
coagulation factor V
coagulation factor XI
vWF:CP (ADAMTS 13)
• target level: 15-20% factor activity
Cross-sectional Guidelines for Therapy with Blood Components and Plasma Derivatives
Executive Committee of the German Medical Association
on the recommendation of the Scientific Advisory Board, 4th edition 2009
12. British guidelines for the use of
FFP
prolonged massive transfusion
with multi-factor deficiency
O'Shaughnessy, D. F. et al. Br. J. Haematol (2004) 126: 11
13. Austrian TIC-guidelines: FFP
The usual dose of 10–15 mL/kg FFP is insufficient
30 mL/kg FFP
No consensus on fixed ratio FFP:RBC:platelet concentrate
In cases of relevant clotting disorder with
persistent bleeding, factor concentrates should be used
FFP, fresh frozen plasma; RBC, red blood cells
“Recommended”
www.oegari.at
AINS 2010; 45:552-61
14. We suggest that FFP may be used
if no other fibrinogen source is available
2 C
FFP
Eur J Anaesthesiol 2013; 30: 270-382
15. 1
5
20
2
5
33
18
14
12
11
4
59
1
3
8
12
2
26
0% 20% 40% 60% 80% 100%
Blood loss
Allogeneic transfusions
Survival
LOS
Plasma fibrinogen
Overall
Outcomes
Benefit
No difference
Decrement
Poor efficacy of plasma
Kozek. Critical Care 2011;15: R239
awareness for poor efficacy ?
18. Schöchl. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 20
Minerva Anestesiol 2005 JSTEM 2012
Concentrate-based conceptá 50 ml
31. We recommend avoiding hypervolemia with crystalloids
or colloids to a level exceeding the interstitial space in
steady state, and beyond an optimal cardiac preload
1B
Avoid hypervolaemia
Eur J Anaesthesiol 2013; 30: 270-382
33. Preload optimization
We recommend aggressive and timely stabilisation of
cardiac preload throughout the surgical procedure,
as this appears beneficial to the patient
1B
Eur J Anaesthesiol 2013; 30: 270-382
34. Tissue perfusion
We recommend repeated measurements of a combination of Hk/Hb,
serum lactate, and base deficit in order to monitor tissue perfusion,
tissue oxygenation and the dynamics of blood loss during acute
bleeding. These parameters can be extended by measurement of
cardiac output, dynamic parameters of volume status (e.g. SVV,
PPV) and central venous saturation
1C
Eur J Anaesthesiol 2013; 30: 270-382
41. Contraindications of HES 130
(after PRAC/CMDh 10/2013):
• Sepsis
• Burn trauma
• Renal insufficiency or RRT
• intracranial or cerebral bleeding
• Critical illness (on ICU)
• Hyperhydratation, incl. pulmonary edema
• Dehydratation
• Severe coagulopathy
• Severe liver dysfunction
42. CMDh Statement:
Information for healthcare professionals
(1) Because of the risk of kidney injury and mortality HES solutions must no longer be used in
patients with sepsis, burn injuries or critically ill patients.
(2) HES solutions should only be used for the treatment of hypovolaemia due to blood loss
when crystalloids alone are not considered sufficient.
(3) There is a lack of robust long-term safety data in patients undergoing surgical procedures
and in patients with trauma. The expected benefit of treatment should be carefully weighed
against the uncertainties with regard to long-term safety, and other available treatment
options should be considered. Additional studies will be performed with HES solutions in
patients with trauma and in elective surgery.
(4) HES solutions should be used at the lowest effective dose for the shortest period of time.
Treatment should be guided by continuous haemodynamic monitoring so that the infusion
is stopped as soon as appropriate haemodynamic goals have been achieved.
(5) HES solutions are now contraindicated in patients with renal impairment or renal
replacement therapy. The use of HES must be discontinued at the first sign of renal injury.
An increased need for renal replacement therapy has been reported up to 90 days after
HES administration. Patients’ kidney function should be monitored after HES
administration.
(6) HES solutions are contraindicated in severe coagulopathy. HES solutions should be
discontinued at the first sign of coagulopathy. Blood coagulation parameters should be
monitored carefully in case of repeated administration.
CMDh: Co-ordination Group for Mutual Recognition and Decentralised Procedures – Human
43. 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 compared to saline
44. HES crystalloid
RRT 235 196
no RRT 3117 3179
p = 0.044
HES crystalloid
RRT 234 197
no RRT 3118 3178
p = 0.054
X² Test
CHEST: Statistical considerations
if 2 RRT-indications changed….
J. Kreutziger, AIC 2013
45. HES crystalloid
RRT 87 65
no RRT 311 335
p = 0.044
HES crystalloid
RRT 87 66
no RRT 311 334
p = 0.054
X² Test
6S: Statistical considerations
if 1 RRT-indication changed …
J. Kreutziger, AIC 2013
46. Big trial in critical illness
efficacy of initial colloidal volume
therapy
Annane. JAMA 2013;310:1809-17
