damage control resuscitation plasma expanders hemorrhagic shock hypovolemic shock transfusion in shock blood in shock hemotherapy in shock massive transfusion hypotension crystalloids colloids coagulopathy hypothermia acidosis infusion therapy in shock hemoglobin based oxygen carriers prbc ffp platelets transfusion in shock DCR

1. HEMOTHERAPY IN
SHOCK
PRESENTER- DR. SHINY
MODERATOR- DR. NIDHI BANSAL

2. INTRODUCTION
Transfusion support is vital for a patient of trauma with hemorrhagic shock.
The transfusion of the right component to the right patient in the right quantity
and at the right time has been the main focus of attention for critical care
doctors.
Although blood is the ideal resuscitation agent from a physiological
perspective, there are limitations to its use.

8. CASE
•A 57-year-old man was admitted to our ED with right massive hemothorax
•The patient had undergone needle biopsy of the pleura to examine bilateral pleural effusion of
uncommon cause.
•Shortly after his arrival at our hospital, cardiac arrest occurred, and the patient needed ALS.
•We performed right thoracotomy and confirmed a bleeding point from right dorsal 5th I/C artery.
• At surgery, his hemoglobin level was 4.6 g/dL, and his fibrinogen level was 83 mg/dL; blood gas
tests showed a pH of 7.04 and a lactate level of 17.4 mmol/L.
•In addition, body temperature was 32.1 °C;

9. MANAGEMENT
•He already had all the components of the trauma deadly triad.
•A bolus of 2L crystalloid solution was infused.
•Massive transfusion protocol was established and 4 units of FFP, 1 unit of
apheresis platelets and 4 red cells were transfused alongwith which damage
control surgery was initiated.
•The bleeding site was closed with sutures, and the bleeding was stopped. The
patient was saved and successfully managed under intensive care therapy.

10. DISCUSSION
•Initial hemorrhagic shock resuscitation begins with the administration of IV fluids,
followed by transfusion of blood products at a 1:1:1 ratio.
•When the etiology of hypovolemic shock has been determined, blood or fluid loss
replacement should be carried out as soon as possible to minimize tissue ischemia.
•For patients presenting with hypovolemic shock, it is important to differentiate between
hemorrhagic versus non-hemorrhagic hypovolemic shock.
•In terms of hemorrhagic shock resuscitation, using blood products over crystalloid
resuscitation resulted in improved outcomes.

11. Infusion Therapy- Hypovolemic Shock
Use crystalloids in appropriate volume, to prevent fluid overload-
Despite decades of liberal use treating trauma patients, it is now known that
infusing large volumes of crystalloid as a replacement for lost blood worsens the
“vicious cycle of coagulopathy” resulting from hypoxia, acidosis, and hypothermia
that was originally described 35 years ago.
Intravenous fluids are known to dilute clotting factors, cool patients, and create
acidosis.

12. 3 Types of Fluids
1. Crystalloids
•Lactated Ringer's solution is the most widely available and frequently used balanced
salt solution.
•Crystalloid is the first fluid of choice for resuscitation.
•Immediately administer 2 L of isotonic sodium chloride solution or lactated Ringer’s
solution in response to shock from blood loss.
•3 L of fluid need to be administered to raise the intravascular volume by 1 L.

13. 2. Colloids- Several colloid solutions were studied in clinical practice including
human albumin, hydroxyl ethyl starch (HES), and dextran colloids restore
volume in a 1:1 ratio but it has been associated with the induction of
coagulopathy.
3. Hypertonic saline (5 ml/kg NaCl 7.5%)- In patients with hemorrhagic shock,
hypertonic saline has the theoretical benefit of increasing intravascular volume
with only small amounts of fluid.

15. HEMOTHERAPY- SHOCK
Balanced (1:1:1) Resuscitation-
PRBCs should be transfused if the patient remains unstable after 2000 mL of
crystalloid resuscitation.
For acute situations, O-negative noncrossmatched blood should be administered.

16. Haemorrhagic Shock Hemotherapy
•Before 1995, aggressive resuscitation using crystalloid and RBCs was the
standard of care in civilian hospitals.
•In the late 1990s, trauma surgeons started to recognize the potential deleterious
effects of too much crystalloid, including increased risk of acute respiratory
distress syndrome, multiple-organ failure, and abdominal compartment
syndrome.

17. •Gradually, and after new data became available from the military experience
supporting combat casualties in the Iraq and Afghanistan wars, a new approach to
hemorrhagic shock, damage control resuscitation, was adopted.
•This approach included the early transfusion of plasma and platelets in addition
to RBCs while minimizing crystalloid use.
•An increased ratio of plasma to RBCs or platelets to RBCs was independently
associated with decreased 6-hour mortality.

18. Hemotherapy- Hemorrhagic Shock
Whole blood-
With the advent of blood component therapy, the use of whole blood as a resuscitation fluid has
become obsolete.
It may only be suggested if blood loss is >40%.
Whole blood is deficient in clotting factors and has high levels of potassium, ammonia, and
hydrogen ions. Although it provides volume expansion along with increased oxygen-carrying
capacity, there can be volume overload before the needed components are replenished.

19. Packed red blood cells
Since the central pathophysiology of hemorrhagic shock is failure of oxygen
delivery, timely administration of red blood cells is the most important
component of resuscitation.
Blood loss greater than 25% to 30% usually requires transfusion of packed red
blood cells in addition to crystalloids.

20. Fresh frozen plasma (FFP)
•utilized for its clotting factor content in trauma resuscitation.
•Administration of FFP should be guided by serial measurement of clotting times,
fibrinogen levels, prothrombin time (PT), and (APTT).

21. Platelets
The decision to transfuse platelets in shock should be based on the extent of the
thrombocytopenia, the presence or absence of active bleeding, and the need for
surgical intervention.

22. Recombinant erythropoietin
Hemorrhagic shock leads to suppression of erythrocyte production due to the
effect of cytokines released as a part of the systemic inflammatory response.
High levels of erythropoietin achieved by recombinant erythropoietin
administration have established a robust erythrocyte response in the seriously
injured patient.

23. Hemoglobin-based oxygen carriers
•HBOCs represent an attempt to create a resuscitative fluid with the O2-carrying
capacity of red blood cells but without the need for cross-matching or the potential for
viral transmission.
•These solutions are either human or bovine in origin and consist of Hb dimers or
tetramers.
•They have shorter half-lives than red blood cells (hours to days).
•Studies have shown promising results, demonstrating that HBOCs are capable of
replacing all or part of the transfusion requirements in surgerirs and shock.

24. RECENT ADVANCES

27. REFERENCES
1. Resuscitation for Hypovolemic Shock Kyle J. Kalkwarf, Bryan A. Cotton
2. Transfusion protocol in trauma Paramjit Kaur, Sabita Basu,1 Gagandeep Kaur,1 and Ravneet Kaur1
3. AABB Technical Manual
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141982/