This document discusses fluid resuscitation strategies in trauma patients. It outlines the goals of fluid resuscitation as replacing volume loss, improving blood pressure, and improving tissue perfusion and oxygenation. It describes the evolution from aggressive to restrictive fluid resuscitation strategies, including permissive hypotension which aims to increase systolic blood pressure while keeping it lower than normal until hemorrhage is controlled. The advantages and types of fluids used, including crystalloids, colloids, and blood products are discussed, along with considerations for different patient populations and injury types.

1. Fluid resuscitation in trauma
Dr P K Maharana.
Department of Anesthesiology.
KIMS, Bhubaneswar.

2. Introduction
• Traumatic injuries account for nearly 10% of
the global burden of disease.
• Uncontrolled post-traumatic hemorrhage is
the major cause of potentially preventable
death among injured patients.

3. Goals of fluid resuscitation
To replace volume loss.
Improve Blood Pressure.
Improve tissue perfusion & oxygenation to
maintain organ functions.

4. Evolving strategies on fluid resuscitation
There is a change in the strategy of fluid resuscitation
from Aggressive to Restrictive.
o Aggressive fluid resuscitation: Earlier, immediate in
trauma patients was the standard approach to restore
circulating volume and maintain organ perfusion.
o Permissive hypotension strategy; Present concept is
restrictive fluid administration strategy, where fluid is given to increase
SBP without reaching normotension.

5. Permissive hypotension
 Permissive hypotension is a strategy to under resuscitate a patient with
fluids to increase the systolic pressure but to keep at a lower than
normal level, until definitive hemorrhage control is obtained.
o Permissive hypotension maintains appropriate organ perfusion, reduces
bleeding and improves mortality.
o A systolic pressure < 100 mm HG has improved survival in penetrating
injury patients.
 Disadvantages associated with Aggressive resuscitations with crystalloid
in trauma.  dilution coagulopathy, hypothermia, “popping the clot”
from rapid increase in systolic BP, increased tissue edema leading
to abdominal compartment syndrome, and
organ failure.
 Because of increased mortality, Permissive hypotension is
contraindicated in TBI.

6. Advantages of Permissive
Hypotension
 Permissive hypotension is associated with
• Decreased incidences of (blood loss, less intra- abdominal
bleeding, risk of intra-abdominal hypertension, acidemia,
hemodilution, thrombocytopenia, coagulopathy, apoptotic
cell death, tissue injury, sepsis)
• Decrease volumes of crystalloid needed,
• Better utilization blood products, &
• Improved organ perfusion and survival.

7. What is hypotensive resuscitation?
• Hypotensive resuscitation: is also known
as permissive hypotension, refers to the principle of
gaining hemorrhage control before restoration of
euvolemia and normal blood pressure.

8. Fluid Resuscitation Strategy
&
type of injury
 A restrictive clear fluid resuscitation policies
• Penetrating injuries: Permitting a SBP(between 60 and 70 mmHg )until the patient can be
taken to the operating theater.
Once hemorrhage has been controlled in theater and blood products are available,
higher blood pressure values may be targeted.
• Blunt injury: A slightly higher SBP of 80–90 mmHg is permitted, again, until
control in theater is achieved and blood products are available, a restrictive policy
is acceptable with slower infusions favored over rapid boluses .
• Traumatic Brain Injury (TBI) : A target of SBP 100-110 mmHg (MAP > 80 mmHg)
(a cerebral perfusion pressure of approximately 60 mmHg) in order to preserve
adequate cerebral perfusion pressure and prevent secondary brain injury.

9. Fluid Responsiveness
Fluid administration is beneficial only if it increases the
stroke volume (SV) and thereby, the cardiac output.
 Patients are considered fluid responsive if SV increases by
at least 10% after a fluid challenge of 500 mL of crystalloid.
• Pulse pressure variation, passive leg raising test, and SV variation
are some reliable markers for assessing fluid responsiveness.
 Clinically the response to intravenous fluid resuscitation is best assessed
basing on improvement of physiological markers ( ↑BP, ↓HR,↓ lactate
and normalizing base deficit) with adequate control of bleeding.
o Responders are considered those that demonstrate these physiological
improvements,
o Non-responders are those that show continued physiological deterioration
despite initial fluid resuscitation.

10. Volume of fluids
 Resuscitation should be limited to clear fluid
only that which is necessary to maintain
adequate organ perfusion until blood products
are available.
Several factors influence decisions at this point of
the resuscitation.
o A). In environments where blood products are
limited judicious use of clear fluids to sustain organ perfusion
while avoiding the negative effects of excess fluid.
o B).

11. Ideal fluid for resuscitation
 Crystalloids and colloids are widely used for fluid
resuscitation, the ideal choice of fluid is still
debated.
• Hypotonic fluids do not stay intravascular. Therefore,
isotonic and hypertonic crystalloids are used for fluid
resuscitation only.
• Isotonic Crystalloids are the most preferred one
: Lactated Ringer’s (LR) or normal saline (NS) is the
primary fluid for resuscitation.
• Colloids: Albumin and gelatin solutions are protein colloids
whereas starches and dextrans are non-protein colloids.

12. Crystalloid versus colloid debate
 SAFE; study compared 4% albumin and NS,
(Saline versus Albumin Fluid Evaluation)
• Both showed clinically equivalent efficacy.
• The volume of fluid administered was less with
albumin than with NS (1:1.4).
• However, in TBI patients, albumin resuscitation
was associated with higher mortality compared
to NS.
• Albumin is contraindicated in TBI cases.

13. Crystalloids or Colloids
 Crystalloids;
o Readily available and inexpensive .
o They are preferred in TBI and in initial resuscitation of trauma patients.
o L-isomer of LR causes less inflammation, immune dysfunction , and
mortality in critically ill patients and is recommended fluid of choice in
hemorrhagic shock patients.
o Chloride-restrictive fluids reduce the risk of renal failure and the need for
renal replacement therapy.
o They may be used as adjuncts to blood products and other therapies.
 HTS is beneficial in patients with brain edema, TBI , or massive
hemorrhage requiring DCS.
o Though HTS contributes to renal failure, it significantly decreases the fluid
requirement and consequent acute respiratory distress syndrome related
to interstitial fluid overload.

14. Colloids
 Colloids remain intravascular longer, rapidly expand plasma
volume, and achieve similar goals quickly with less volume
than crystalloids.
o However, expense and lack of survival benefit over
crystalloids.
o Colloid use is recommended when patients cannot tolerate
large crystalloid volumes and overload is of concern.
o Albumin is contraindicated in TBI, and HES and other
starches are not recommended.
o Owing to the increased risk of kidney injury, colloids should
be cautiously used in patients with renal impairment.
o Renal effects are colloid-specific; albumin displays
renoprotection while HES shows nephrotoxicity.

15. Crystalloids
(NS or Balance Salt Solutions)
NS (0.9%): remains widely used as a resuscitation fluid
and remains the fluid of choice for patients with brain injury,
hyponatremia and metabolic alkalosis.
Balanced salt solutions: ( Ringer’s lactate, Hartmann’s
solution , with a physiological pH and isotonic electrolyte concentration),
being more physiological in nature, are being used more
frequently, showing a trend toward less harm than 0.9%
sodium chloride. Balanced salt solutions preferred in patients
who are acidotic.

16. Balance salt solutions
 Balanced salt solutions: with a physiological pH and isotonic
electrolyte concentration closely resemble human plasma and thus
have a lower sodium and chloride content than 0.9% saline with the
addition of a buffer such as acetate or lactate.
o These fluids (e.g., Ringer’s lactate, Hartmann’s solution) have
minimal effects on pH.
o Hypotonic, so can exacerbate edema, particularly cerebral edema
in the injured brain. Not recommended in TBI.
o Potential interaction between citrate found in stored blood and
bicarbonate, explaining why 0.9% saline is still a commonly used
resuscitation fluid in trauma patients, despite the high chloride
load. Ns compatible with blood where RL not.
o Ns is associated with hyperchloremic acidosis and renal injury.

17. Pre-hospital transport time (PTT)
 Delayed resuscitation seems a better option
when transport time to definitive care is
shorter. (PTT < 10-15 minutes).
 Whereas goal-directed resuscitation with
low-volume crystalloid seems a better option
if transport time is longer ( > 10-15 minutes).

18. Pre-hospital transport time (PTT) &
Crystalloids
 Pre-hospital intravenous fluid administration
decreases mortality in trauma patients,
especially in major injuries and rural settings
when pre-hospital transport time (PTT) is
longer( >10-15 minutes) .

19. Lethal triad of severe injury.
 In severely injured patients, the lethal triads
of injury & haemorrhage are:
• Hypothermia,
• Acidosis, and
• Coagulopathy
 Responsible for exacerbation of hemorrhage.

20. Damage control resuscitation
. Damage control resuscitation combats this
lethal triad and comprises of  permissive
hypotension, hemostatic resuscitation, and
damage control surgery (DCS).
 DCS restores physiology instead of providing
definitive anatomical repair.
• It consists of bleeding control, decontamination,
quick body cavity closure to rewarm the patient, and
planned re-operation for definitive repair.

21. Hemostatic resuscitation
Hemostatic resuscitation involves: early use
of blood and blood products to minimize
coagulopathy, prevent dilutional coagulopathy, and
improve survival.
It entails the use of : plasma, platelets, and red
blood cells in an optimal ratio of 1:1:1 as well as the
use of antifibrinolytic agents such as tranexamic acid
in addition to limiting the use of crystalloids.

22. Trauma Protocol for hemorrhagic shock.

23. Massive blood loss
 In patients with massive blood loss, permissive
hypotension prevents progression to dilutional
coagulopathy of trauma.
 In severe and uncontrolled hemorrhagic shock, controlled
resuscitation (MAP of 40 mmHg) is preferred.
 International guidelines recommend SBP of 80–90 mmHg in
trauma without brain injury and MAP ≥ 80 mmHg in TBI
until major bleeding is controlled.
 New generation gelatins like polygeline may maintain
circulation until blood is available.
 Improvements in BP, MAP, pulse rate, respiratory rate, and
blood pH are noted within 1 h of administration in
hypovolemic trauma patients .

24. Massive transfusion protocol (MTP)
 Massive transfusion protocol (MTP) should be
activated in patients requiring continued
resuscitation and should be started as early as
possible to avoid rapid administration of crystalloids
and post-injury complications such as organ failure
and abdominal compartment syndrome.

25. HES & Critically ill
 Crystalloid versus Hydroxyethyl Starch Trial
(CHEST),
• Hydroxyethyl starch (HES)  Use of HES was
associated with increased renal failure, need
for renal-replacement therapy, and increased
mortality.
• Risks of renal injury and mortality related to
colloids  were observed only in critically ill
patients with sepsis.

26. New generation gelatins
 Gelatins are low molecular weight substances,
• Cheaper than albumin and other synthetic colloids,
• Rapidly excreted by kidneys,
• Even does not accumulate in patients with renal failure.
• Associated with less renal impairment than HES,
• and have no upper limit of volume that can be infused unlike starches and
dextran.( 30ml/kg)
• Gelatins are associated more with anaphylactoid reactions than albumin,
(some recent studies showed no anaphylactic reactions with polygeline) .
• Polygeline has a short half-life of 4–6 h and is readily excreted in the urine and
does not seem to adversely affect renal function .
• In India, Polygeline is routinely used in hypovolemic trauma patients.
• New generation gelatins may have a significant role in remote/rural settings to
prevent crystalloid overuse until definitive care is available and also in low-income
settings where albumin may not be available/affordable.

27. Pediatrics
Initial resuscitation:
• Isotonic and balanced crystalloid (20 mL/kg) is for.
• Fluid volume should be < 40 mL/kg to prevent
dilutional coagulopathy and edema.
Maintenance phase:
Prone to hyponatremia and cerebral edema if
hypotonic solutions are administered excessively .
• So, limited volumes (maximum 2 mL/kg/h) using
flow controllers are recommended.

28. Geriatrics
 Aging causes arterial stiffness and decreased left ventricle
(LV) compliance.
o Hypovolemia decreases preload leading to under-filling of
ventricles with disproportionate drop in cardiac output .
o Therefore, permissive hypotension should be applied
cautiously with adequate monitoring.
o Hypervolemia increases the risk of pulmonary edema due
to decreased LV compliance.
o Echocardiography is recommended to assess fluid
requirements .
 Clear fluid should be limited to 20 mL/kg, blood and blood
products administered early, MAP > 70 mmHg and
hemoglobin levels > 9 g/dL should be maintained.

29. Pregnancy
• Pregnant patients tolerate blood loss better due to
increased circulating blood volume and cardiac output.
• Adequate volume replacement is also necessary for
adequate uteroplacental blood flow.
• Absence of tachycardia and hypotension should not be
considered as the absence of significant hemorrhage.
• Usually hypotension & tachycardia occur after 1500–
2000 mL of hemorrhage.
• The fetal heart rate is sensitive to maternal
hypovolemia and should be monitored.
• Supplemental oxygen should be provided to prevent
maternal and fetal hypoxia.

30. Chronic kidney disease
Both fluid overload and fluid composition affect
the kidneys.
o NS may cause kidney injury and increase acidosis.
o Isotonic saline reduces renal perfusion and
increases the risk of AKI.
o Balanced electrolytes cause less hyperchloremia
and are preferred.
o Due to the risk of kidney injury, chloride-liberal
fluids should be restricted and colloids should
be used cautiously .

31. LV Dysfunction
 Patients with decreased LV compliance:
Excessive fluid administration worsens lung congestion and non-
cardiogenic pulmonary edema resulting in pulmonary hypertension,
right ventricle dysfunction, and further decrease in LV volumes.
o Echocardiography is recommended to assess cardiac load and
cardiac response to fluid administration.
 Cardiac dysfunction should be suspected ?
o Whenever cardiac output monitoring is not available and a patient
is not responding to fluid challenge/norepinephrine.
 In patients with life-threatening hypotension, both vasopressors
and fluids should be given to maintain target arterial pressure.

32. Liver disease
 Cirrhotic patients have elevated cardiac output, decreased systemic
vascular resistance, and low BP.
o This is due to total extracellular fluid overload while there is central
effective circulatory hypovolemia.
o In trauma patients with cirrhosis, fluid loading may be needed. However,
the fluid load may worsen organ function and contribute to ascites.
o In volume-depleted patients, crystalloids are the initial fluid of choice (10–
20 mL/kg). MAP ≥ 60 mmHg is appropriate in cirrhotic patients.
o Balanced salt solutions are preferred in hyperchloremic acidic patients.
o Therapeutic paracentesis is recommended in patients with tense ascites.
o Pulmonary artery catheter or echocardiography should be used to
monitor fluid overload.
o Albumin should be administered following large-volume paracentesis
(> 5 L) as it prevents post-paracentesis circulatory dysfunction better
than crystalloids.
o HES is contraindicated due to nephrotoxicity.

33. Conclusions
• Fluid resuscitation strategies have evolved with time.
• Different traumas need different fluids and different
resuscitation strategies.
• Pre-hospital trauma care reduces mortality in rural/remote
settings.
• Delayed fluid resuscitation is preferred when transport
time to definitive care is shorter whereas goal-directed
resuscitation with low-volume crystalloid is preferred if
transport time is longer.
 Adhering to evidence-based clinical practice guidelines and
local modifications based on patient population, available
resources, and expertise may improve patient outcomes.