fluid and product resuscitation

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FLUID AND PRODUCT RESUSCITATION

Allen Clark M.D.

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Fluid and Product Resuscitation

I have no financial disclosures

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Case Presentation 25y/o G2P1001 undergoing primary cesarean

section for breech Starting Hgb 9.0 Intraoperative EBL suspected at 1000ml, still

having difficulty obtaining control of bleeding Vitals: 110/60, P95, rr18, T36.6 Surgeon requests to start transfusing 2 units

pRBC Anesthesia disagrees and wants to not give

the transfusion

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Case Presentation 34y/o G4P3003 at 39 and 0 undergoing

her 4th cesarean section Starting Hgb 11.0 Anterior placenta, no signs of accreta on

ultrasound h/o uterine atony in prior cesarean

section

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Objectives Define and classify hemorrhage Review different types of fluid

resuscitation available Discuss the different products used in

resuscitation Review massive transfusion protocols Preview newer resuscitation strategies

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Hemorrhage In 2005, hemorrhage was the third

leading cause of maternal death

Per the WHO, leading cause of death worldwide

Highly preventable, with aggressive therapy and appropriate management

Mortality has been improving with the development and implementation of massive transfusion protocols

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Hemorrhage in Pregnancy Pregnancy is a protected state 40-50% volume expansion Increase in RBC mass by 20-30% Elevated Cardiac Output, 30-50% Decreased systemic vascular resistance Increase in fibrinogen, coagulation

factors I, VII, VIII, IX, X

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SVR, CO, and BP response to blood loss

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Classification of Hemorrhage -OB

Hemorrhage Class

Acute Blood Loss

% Lost Physiologic Response

1 900ml 15 Asymptomatic

2 1,200-1,500 20-25 Tachycardia and tachypnea, Narrowed pulse pressure, Orthostatic Hypotension, Delayed hypothenar refilling

3 1,800-2,100ml 30-35 Worsening tachycardia and tachypnea, Hypotension, Cool extremities

4 >2,400ml 40 Shock, Oliguria, Anuria

Total blood volume = 6,000ml, Average for 60kg pregnant woman

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Classification of Hemorrhage -OB

Hemorrhage Class

Acute Blood Loss

% Lost Physiologic Response

1 900ml 15 Asymptomatic

2 1,200-1,500 20-25 Tachycardia and tachypnea, Narrowed pulse pressure, Orthostatic Hypotension, Delayed hypothenar refilling

3 1,800-2,100ml 30-35 Worsening tachycardia and tachypnea, Hypotension, Cool extremities

4 >2,400ml 40 Shock, Oliguria, Anuria

Total blood volume = 6,000ml, Average for 60kg pregnant woman

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Classification of Hemorrhage- GYN

Class 1 Class 2 Class 3 Class 4

Blood Loss <750ml 750-1500ml 1500-2000ml >2000ml

Blood volume <15% 15-30% 30-40% >40%

Pulse(beats/min)

<100 >100 >120 >140

Blood Pressure Normal/Increase

Orthostatic Decreased Decreased

Pulse Pressure Normal Decreased Decreased Decreased

Capillary Refill Normal May be delayed

Usually Delayed

Always Delayed

Respirations Normal, >14 20-30 30-40 Near Respiratory Collapse >35

Urinary Output >30ml/hr 20-30ml/hr 5-15ml/hr Essentially anuric

Mental status Normal Anxious Confused Obtunded

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Classification of Hemorrhage- GYN

Class 1 Class 2 Class 3 Class 4

Blood Loss <750ml 750-1500ml 1500-2000ml >2000ml

Blood volume <15% 15-30% 30-40% >40%

Pulse(beats/min)

<100 >100 >120 >140

Blood Pressure Normal/Increase

Orthostatic Decreased Decreased

Pulse Pressure Normal Decreased Decreased Decreased

Capillary Refill Normal May be delayed

Usually Delayed

Always Delayed

Respirations Normal, >14 20-30 30-40 Near Respiratory Collapse >35

Urinary Output >30ml/hr 20-30ml/hr 5-15ml/hr Essentially anuric

Mental status Normal Anxious Confused Obtunded

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Per The ICU Book Class 1- Minimal physiologic changes Class 2- Tachycardia, narrowing pulse

pressure Typically compensatory mechanism such as

renin-angiotensin compensate Class 3- Compensatory mechanisms

begin to fail Class 4- Life threatening

If this reaches ischemic injury in the heart or brain, death typically results

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Volume Resuscitation IV access On the basis of speed of fluid infusion,

what is preferred, a 16 gauge peripheral IV catheter or a 16 gauge central venous catheter??

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Surprise?

Mateer JR Thompson BM, Aprahamian C, et al. Rapid fluid resuscitation with central venous catheters. Ann Emerg Med 1983; 12:149-152

• Q= Rate, P= pressure, r= radius, = viscosity, L= length

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What goes in the IV? Crystalloids, Colloids, Blood? Surgical specialties tend to use lactated

ringers, emergency rooms use normal saline, trauma surgeons are starting to use blood products

Why do we use lactated ringers? Should we?

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Crystalloids Electrolyte solutions with small molecules

that freely diffuse throughout extracellular space

Mostly Na and Cl Sodium- abundant in extracellular fluid, 75%

in interstitial fluids For IV administered Na, 75% will therefore

end up in interstitial fluids Therefore, the predominant effect of

crystalloids is to expand INTERSTITIAL volume, not plasma volume

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Crystalloids Therefore, how much of 1 L of normal

saline stays in the plasma? A – 1000 ml B – 700 ml C – 500 ml D – 275 ml E – 0 ml

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Crystalloids 275ml of a liter of normal saline stays in

plasma, 825ml in interstitial volume But wait Allen, 275 + 825 = 1100. . . Prepare to have your mind blown

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Crystalloid Infusion Fluids

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Isotonic Saline – 0.9% Sodium Chloride

Slightly higher Na concentration then plasma 154 vs 140 mEq/L

Much higher Cl Concentration 154 vs 103mEq/L

Lower pH 5.7 vs 7.4 Slightly higher osmolality 308 vs 290

mOsm/L This causes a shift of approximately 100ml of

fluid from intracellular to extracellular upon administration, causing total volume expansion to be 1100ml . . .BOOM!

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Isotonic Saline - Disadvantages

Large volumes of isotonic saline will produce a metabolic acidosis

Hyperchloremic acidosis produced by the high levels of Cl in isotonic saline

Though this is typically without clinical consequence, it has potential negative consequences if it delays identification of lactic acidosis or is combined with another type of acidosis (ie respiratory from anesthesia)

Scheingraber S, Rehm, M, et al. Rapid saline infusion produces hyperchloremic acidosis in patient undergoing gynecologic surgery. Anesthesiology. 1999, 90: 1265-70

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Lactated Ringer’s

Contains Potassium and Calcium in approximately the same ionized concentrations in plasma

This causes a lower sodium concentration LR also contains lactate, which allows reduction of the chloride

concentration With a chloride concentration closer to that of plasma, there is no risk

of hyperchloremic metabolic acidosis with large infusions

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LR, what can’t it do It can’t be infused with some meds,

because the calcium can bind to some drugs

Examples include aminocaproic acid, amphotericin, ampicillin, thiopental

Can bind citrated anticoagulant of blood products and cause clotting

If volume of LR does not exceed 50% of pRBC volume, this does not occur

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Anyone ever done a study on this stuff

In 2009, 20 pigs underwent liver injuries, hemorrhaged for 30 min, and then in a blinded fashion given LR or NS for resuscitation

Given IV fluid to maintain preinjury MAP Monitored oxygenation and pulmonary

edema, total fluid volume given, pH, and blood loss

Little impact on oxygenation LR has favorable effects on pH,

coagulation and hemodynamicsPhillips CR, Vinecore K, et al. Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on exygenation, extravascular lung water and hamodynamics. Crit Care, 2009; 13:

R30

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Anyone else In 2007, 20 pigs underwent liver injuries,

hemorrhaged for 30 minutes, then underwent NS or LR resuscitation to maintain the preinjury MAP for 90 minutes

Results: it took 256ml/kg of NS vs 125ml/kg of LR to maintain MAP, urine output for NS was 46.6ml/kg vs LR 18ml/kg,

NS animals developed dilutional coagulopathy, had lower fibrinogen, lower platelet count, and lower PT

NS animals developed hyperchloremic metabolic acidosis and coagulopathy

LR animals developed lacticemia not associated with acidosis

Todd SR, Malinoski D, et al. Lactated ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. Trauma. 2007 March; 62, 636-639

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I dare to ask, anyone else In 2006, 20 pigs underwent liver injuries,

hemorrhaged for 30 minutes, and then given either NS or LR to maintain MAP at baseline for 90 minutes

Baseline and Q30 min Lactate, ABG, chemistry, PTT, PT and fibrinogen were taken, and thrombelastography (TEG) was performed

Kiraly LN, Differding JA, et al. Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic

Shock Swine Model. Trauma: 2006; 61:57-65

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Pause, whats TEG

R= reaction time = time to onset of clot formation, elongation = coagulation factor deficiency

Alpha= rapidity of fibrin buildup and cross linking = affected by fibrinogen and platelets

K speed to reach certain level of clot strength = platelets and fibrinogen function

MA= maximum amplitude = strength of clot, affected primarily by platelets but also fibrinogenKiraly LN, Differding JA, et al. Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR)

Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine Model. Trauma: 2006; 61:57-65

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And the results With similar injuries, NS group had greater

overall blood loss and required 2x the amount of fluid to maintain MAP

NS group was more acidotic from 30 minutes on

NS group had lower hematocrit, greater PT and PTT times, and a greater R time, all statistically significant

Conclusion: NS modulates the hypercoagulable state seen after injury, resulting in increased blood loss

Kiraly LN, Differding JA, et al. Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic

Shock Swine Model. Trauma: 2006; 61:57-65

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Can someone please stab a human

In 2005, 51 patients undergoing renal transplant were placed in a randomized double blinded study to receive LR or NS intraoperative

LR is typically not used in this population over concern of the development of hyperkalemia in a population with ESRD, standard of care is NS

Rate of fluids was given as clinically indicated and not according to an algorithm

Primary outcome measure was serum creatinine concentrations on POD 3

Secondary outcomes included post op urine output, creatinine clearance, rejection, graft loss, intraoperative acid base balance, intraoperative potassium concentrations, blood loss and transfusions requirements and hospital length stay

O’malley CM, Frumento RJ, Hardy MA, etal. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation. Anesthia Analg 2005; 100:1518-24

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And the humans showed. . .

Serum creatinine POD 3 NS 2.3±1.8, LR 2.1±1.7

Seven units of packed red blood cells were administered in the NS group versus three units in the LR group.

Potassium concentrations exceeded 6.0mEq/L in 5/26 NS patients, and 0/25 LR patients

The 5 patients in the NS study were treated for hyperkalemia


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And the humans showed . . .

8/26 NS patients developed metabolic acidosis and required sodium bicarbonate and 0/25 patients in the LR group developed metabolic acidosis

This study was then terminated due to safety concerns of giving patients NS intraoperatively


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Conclusion to the LR vs NS battle

Difficult to say if isotonic saline’s side effects directly change clinical outcomes

Based on this data, there are benefits to LR over normal saline

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Dextrose Originally developed to provide calories

before the introduction of enteral and pareneral nutrition

D5- 50grams dextrose/1 liter = 170kcal

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Dextrose D5W – ineffective at expanding plasma

volume, less then 10% stays in plasma 2/3 of the volume ends up inside cells,

causing cellular swelling If circulatory flow is compromised, 85% of

glucose metabolism is converted to lactate production

This causes a metabolic acidosis when patients with circulatory compromise receive dextrose solutionsDeGoute CS, Ray MJ, Manchon M et al. Intraoperative glucose infusion and blood lactate: endocrine and metabolic relationships during abdominal aortic surgery. Anesthesiology

1989;71:355-361

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Colloids

Contain large, poorly diffusible, solute molecules designed to keep water in the vascular space

Primary protein doing this in plasma is albumin, responsible for 75% of colloid osmotic pressure

The idea of the colloid fluids is to increase the colloid osmotic pressure in the vascular space and bring water into the circulators system

Fluid Na Cl K Osmolality (mOsm/L)

Albumin 5%

150 150 < 2 300

Hetastarch 6%

154 154 0 308

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Colloids’ Turn So, the infusion of 1 Liter of 5% Albumin

expands the plasma volume how much? A – 1000ml B – 700ml C – 500ml D – 275ml E – 0ml

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Colloids turn 700ml increase in the plasma volume and

300ml increment in the interstitial fluid volume

Remembering that about 275ml of NS would stay in the plasma volume

Colloid fluids are 3 times more effective than crystalloids at increasing plasma volume

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Albumin Heat treated preparations of human serum

albumin, available in 5% (50g/L) and 25% solutions (250g/L)

5% albumin comes in 250ml doses and 25% albumin comes in 50 or 100ml doses

5% albumin has equivalent concentrations and colloid osmotic pressure to plasma

70% of fluid infused stays in plasma volume for several hours, effect lost completely after 12 hours

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Albumin, important note 25% albumin does not provide

replacement volume It only causes a shift of fluid from

interstitial to intravascular IT IS NOT A VOLUME REPLACEMENT

THERAPY and can NOT be used in acute blood loss or dehydration

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Albumin, a quick history In 1998, a Cochrane meta-analysis of 30 randomized

control trials of 1419 patients Results: “Pooled relative risk of death with albumin

administration was 1.68 (1.26 to 2.23).” “We found no evidence that albumin reduced

mortality and a strong suggestion that it might increase the risk of death in patients with hypovolaemia, burns, or hypoproteinaemia. Overall, the risk of death in patients treated with albumin was 6% (95% confidence interval 3% to 9%) higher than in patients not given albumin.”

Needless to say, this hurt the use of albumin for resuscitation

Cochrane Injuries Group albumin reviewers. Human albumin administration in critically ill patients: systematic review of randomized, controlled trials. Br Med J 1998;317: 235-240

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Albumin fought back In 2004, a double blinded randomized control

trial including 7000 patients was published in the NEJM, 3497 received albumin, 3500 received NS

SAFE trial (Saline vs Albumin Fluid Evaluation) 7000 ICU patients, admitted for all reasons,

primary outcome was death from any cause at 28 days

726 deaths in albumin group, 729 deaths in normal saline group

In conclusion, similar outcomes of 4% albumin as NS

SAFE study investigators. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. N Engl J Med 2004;350:2247-56.

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Albumin now 2011 Cochrane review of mortality in 38

studies, including the safe study Mortality the primary outcome in all

studies “For patients with hypovolaemia, there is

no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline.”

Albumin Reviewers. Human albumin solution for resuscitation and volume expansion in critically ill patients. Chochran Database Systematic Review. 2011 Oct 5;(10):CD001208

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Hetastarch Hydroxyethyl start is a starch polymer available in a

6% solution in isotonic saline Equivalent to 5% albumin as a plasma volume

expander Is less costly then albumin When more then 1500ml given in 24 hours, can cause

coagulopathy Inhibits factor VIII, von Willebrand factor, and impair

platelet adhesiveness Broken down by amylase and filtered out of the

kidneys, so can also cause a transient hyperamylasemia with no deleterious side effects

Mixed literature results

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So. . . Crystalloids or Colloids?

Due to the transcapillary refill mechanism in hemorrhage, crystalloids gained a strong following among surgical specialties

The majority of the data is from the SAFE trial 2011 Cochrane review of 3870 and 3884

patients receiving crystalloid or colloid solutions, 56 randomized controlled trials with mortality data

Conclusion: “The review of trials found no evidence that colloids reduce the risk of dying compared with crystalloids.”

Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in criticallyill patients (Review). The Cochrane Library. 2011, Issue 3

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How will I use this information

Any patient undergoing surgery needs LR Any patient with hemorrhage should get

LR In the ED, especially for operative

patients, Isotonic Saline should not be used

Albumin is a fine alternative, but given increased cost, I would not use it routinely

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Packed Red Blood Cells Only blood product to provide oxygen-

carrying capacity 300ml volume 250ml RBCs and 50ml plasma 70kg patient, 1 unit pRBC will raise

hemoglobin 1g/dl

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Platelets Separated from whole blood and stored in

plasma 1 unit will increase platelet count

7,500/mm3 Transfused in concentrations of 5-10 Masonic’s is in concentrations of 5 pooled Single donor preferred over multiple to

decrease risk of antigenic exposure, but very difficult if multiple infusions of platelets is necessary

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Fresh Frozen Plasma Plasma extracted from whole blood Contents- fibrinogen, antithrombin III,

clotting factors V, XI, XII 250ml Volume Goal- improve coagulation profile and

volume resuscitation Monitor- Fibrinogen- 1 unit should raise

fibrinogen level by 5-10mg/dl

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Cryoprecipitate The precipitate from thawed FFP Rich in fibrinogen, factor VIII, von

Willebrand’s factor, factor XIII Minimal volume- 40ml Monitor with Fibrinogen- increase by 5-

10mg/dl

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ACOG Guidelines

When is blood transfusion recommended? “Necessary with the extent of blood loss is

significant and ongoing, particularly if vital signs are unstable”

Martin SR, Strong TH. Transfusion of blood components and derivatives in the obstetric intensive care patient. Obstetric intensive care manual. 2nd edition. New York. McGraw Hill 2004

American college of obstetricians and gynecologists. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists Number 76, October 2006;108:1039-1047

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Trauma Friends? Level 1 Recommendations for critically ill

patients 1. RBC transfusion is indicated for patients with

evidence of hemorrhagic shock. 2. RBC transfusion may be indicated for patients

with evidence of acute hemorrhage and hemodynamic instability or inadequate oxygen delivery.

3. A “restrictive” strategy of RBC transfusion (transfuse when Hb 7 g/dL) is as effective as a “liberal” transfusion strategy (transfusion when Hb 10 g/dL)

Napolitano LM, Kurek S, Luchette FA, et al. Clinical Practice Guideline: Red Blood Cell Transfusion in Adult Trauma and Critical Care. Trauma. 2009 Volume 67, 6;1439-42.

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Trauma Friends Continued Level 2 Recommendations for critically ill patients 4. The use of only Hb level as a “trigger” for transfusion should be avoided.

Decision for RBC transfusion should be based on individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters.

5. In the absence of acute hemorrhage, RBC transfusion should be given as single units.

6. Consider transfusion if Hb 7 g/dL in critically ill patients requiring mechanical ventilation. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients requiring mechanical ventilation.

7. Consider transfusion if Hb 7 g/dL in resuscitated critically ill trauma patients. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in resuscitated critically ill trauma patients.

8. Consider transfusion if Hb 7 g/dL in critically ill patients with stable cardiac disease. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients with stable cardiac disease.

9. RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients.Napolitano LM, Kurek S, Luchette FA, et al. Clinical Practice Guideline: Red Blood Cell Transfusion

in Adult Trauma and Critical Care. Trauma. 2009 Volume 67, 6;1439-42.

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Trauma Friends Continued Level 2 Recommendations for critically ill patients 4. The use of only Hb level as a “trigger” for transfusion should be avoided.

Decision for RBC transfusion should be based on individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters.

5. In the absence of acute hemorrhage, RBC transfusion should be given as single units.

6. Consider transfusion if Hb 7 g/dL in critically ill patients requiring mechanical ventilation. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients requiring mechanical ventilation.

7. Consider transfusion if Hb 7 g/dL in resuscitated critically ill trauma patients. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in resuscitated critically ill trauma patients.

8. Consider transfusion if Hb 7 g/dL in critically ill patients with stable cardiac disease. There is no benefit of a “liberal” transfusion strategy (transfusion when Hb 10 g/dL) in critically ill patients with stable cardiac disease.

9. RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients.Napolitano LM, Kurek S, Luchette FA, et al. Clinical Practice Guideline: Red Blood Cell Transfusion

in Adult Trauma and Critical Care. Trauma. 2009 Volume 67, 6;1439-42.

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Trauma Friends Continued 4. The use of only Hgb level as a

“trigger” for transfusion should be avoided. Decision for RBC transfusion should be based on individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters.

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And the evidence? In 1999, a multicenter randomized

control trial was published in the NEJM Compared “restrictive” vs “liberal”

transfusion groups Restrictive- maintain Hgb 7.0-9.0 g/dl and

transfuse at less then 7.0 g/dl Liberal- maintain Hgb 10.0-12.0 g/dl and

transfuse at less then 10.0 g/dl Primary outcome was death of all causes

at 30 daysHebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of

transfusion requirements in critical care. NEJM 1999; 340:6, 409-417

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And the evidence? Enrolled 838 patients, 418 to restrictive

and 420 to liberal Primary outcome- Mortality in restrictive

group 18.7%, in liberal group 23.3% Conclusion “The restrictive transfusion

strategy was at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients with euvolemia”

Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. NEJM 1999; 340:6, 409-417

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Bring it back to hemorrhage This study is excellent at helping us to

assess critically ill patients who are not hemorrhaging, but what about our bleeding patients

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IMMC Massive Transfusion Protocol

Decision to initiate by the Attending Physician

Cycle 1 : 4 units pRBC brought to room immediately

Cycle 2: 6 units pRBC, 4 units FFP, 1 single donor platelets, 10 units cryoprecipitate

Cycle 3: Repeat cycle 2 Cycle is to continue to repeat until

cancelled by attending physician!

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Does a protocol work? We will need to trust our friends, the

trauma surgeons We have to trust them, as approximately

1 in 3 Illinois Masonic OB/GYN Physicians are married to trauma surgeons

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Retrospective Cohort Study Created a Trauma Exsanguination Protocol

Cycle 1: 10 units uncrossed pRBC, 4 units AB neg plasma, 2 units single donor platelets

Cycle 2: 6 units pRBC, 4 units thawed plasma, 2 units single donor platelets

Cycle 3: repeat until ended by attending Cryoprecipitate available upon requestCotton BA, Gunter OL, Isbell J. et al. Damage control hematology: the impact of a trauma

exsanguination protocol on survival and blood product utilization. J Trauma 2008;64: 1177-1182

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Compared 117 pre-TEP patients with 94 TEP patients

Cotton BA, Gunter OL, Isbell J. et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma 2008;64: 1177-1182

• 74% reduction in the odds of mortality at 30 days

• Reduced crystalloid use, reduced overall product transfused

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2009, community hospital in Santa Maria, CA implimented a hemorrhage assessment and response protocal

Patients were assessed for risk upon admission, and protocol algorithms were put in place for differing degrees of hemorrhage

All staff were trained together in the implimentation

Compared the 12 month period prior to implimentation to the 12 month period after

Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.

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Initial triage

Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol

2011;205:368.e1-8.

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Stage 0


66Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1-8.

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Stage 3 “Maternal hemorrhage pack” 3 units pRBC, 2 units FFP, 1 U platelets,

and 10 units cryopercipitate Blood to FFP was in a 3:2 ratio for the

first 2 rounds, then changed to a 1:1 ratio for anything beyond 6 units pRBC and 4 units FFP

Goals: hematocrit >24%, INR < 1.4, platelets >50,000/uL, Fibrinogen >100,000 mg/dl


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And the study showed Compared 2939 preprotocol deliveries

with 2874 post protocol deliveries Overall hemorrhage rate 3.6% Effects of protocol were decreased

severity of hemorrhage overall, decreased average number of pRBC transfused per patient in the stage 3 category from 16.7 6.3, decreased incidence of DIC of 64%, and more confident staff measured via a survey

Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol

2011;205:368.e1-8.

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Area’s to Explore Acute normovolemic hemodilution Recombinant factor VIIa

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What is Acute Normovolemic Hemodilution

Remove 500-1000ml blood before surgery

Replace with crystalloids Perform surgery Once bleeding is controlled, re-infuse the

removed blood

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What’s wrong with pRBC? Expense Risk of transfusion reaction Risk of infectious disease

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Sorry, a British Review Immediate pre operative collection in the

OR of patients blood replaced in a 3:1 ratio by crystalloids

Tends to be 2-3 units Stored in citrated bags, 6 hours at room

temp and 12 hours refrigerated Requirements- Starting Hgb >10.0g/dl, no

myocardial disease, pre op EBL >20% blood volume

S. Catling, Blood conservation techniques in obstetrics: a UK perspective, International Journal of Obstetric Anesthesia, Volume 16, Issue 3, July 2007, Pages 241-249,

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British Review Continued Body compensates for acute loss of blood

by increasing O2 extraction and increasing cardiac output

Intraop blood loss is “Hgb poor blood” Blood is replaced before leaving the OR Patient receives their own RBC’s and

platelets back If IV tubing is kept in contact at all times,

this is acceptable by most Jehovah's witnesses


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The Catch Insufficient level 1 evidence to suggest

that ANH reduces allogenic transfusions Therefore no group has yet to make

recommendations for or against this technique

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Recombinant Activated Factor VII

Precursor to extrinsic clotting cascade Used in cases of massive procoagulant

factor consumption Can reverse DIC in 10 minutes IV dose 60-100micrograms/kg Half life is 2 hours Though intended for use in patients with

thrombophilia, has been used off label to reverse DIC

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Risks of Recombinant Activated Factor VII

In a 2010 meta analysis of 35 placebo controlled trials using factor rFVIIa for treatment or prevention of bleeding

9.0% risk of thrombotic event, with an increased risk of an arterial thrombosis

No change in risk of venous thrombotic event

Levi M, Levy JH, Andersen HF, Truloff D.Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010; 363:1791-9.

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AJOG December 2011 “With the increasing incidence of cesarean

sections and resulting placentation abnormalities, it is necessary to explore interventions that can limit transfusion requirements, for example normovolemic hemodilution, recombinant factor VIIa, pelvic vessel embolization, and cell saver”

Pacheco LD, Saade GR, Gei AF, et al. Cutting-edge advances in the medical management of obstetrical hemorrhage. AJOG. December 2011. 205;6: 526-532.

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Conclusions Lactated ringers is preferred over normal

saline Transfusions of pRBC should be given

when patient has symptomatic anemia Intraoperative blood transfusions due to

hemorrhage should be given aggressively Massive transfusion protocol’s are a must

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Case Presentation 25y/o G2P1001 undergoing primary cesarean

section for breech Starting Hgb 9.0 Intraoperative EBL suspected at 1000ml, still

having difficulty obtaining control of bleeding Vitals: 110/60, P95, rr18, T36.6 Surgeon requests to start transfusing 2 units

pRBC Anesthesia disagrees and wants to not give

the transfusion

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Case Presentation 34y/o G4P3003 at 39 and 0 undergoing

her 4th cesarean section Starting Hgb 11.0 Anterior placenta, no signs of accreta on

ultrasound h/o uterine atony in prior cesarean

section

84

THANK YOU! Thanks to Dr. Rojas and Dr. Witkowski for

reviewing my presentation

85

Questions?

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References Mateer JR Thompson BM, Aprahamian C, et al. Rapid fluid resuscitation with central venous catheters. Ann Emerg

Med 1983; 12:149-152 Scheingraber S, Rehm, M, et al. Rapid saline infusion produces hyperchloremic acidosis in patient undergoing

gnecologic surgery. Anesthesiology. 1999, 90: 1265-70 Phillips CR, Vinecore K, et al. Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects

on exygenation, extravascular lung water and hamodynamics. Crit Care, 2009; 13: R30 Todd SR, Malinoski D, et al. Lactated ringer’s is superior to normal saline in the resuscitation of uncontrolled

hemorrhagic shock. Trauma. 2007 March; 62, 636-639 Kiraly LN, Differding JA, et al. Resuscitation With Normal Saline (NS) vs. Lactated Ringers (LR) Modulates

Hypercoagulability and Leads to Increased Blood Loss in an Uncontrolled Hemorrhagic Shock Swine Model. Trauma: 2006; 61:57-65


DeGoute CS, Ray MJ, Manchon M et al. Intraoperative glucose infusion and blood lactate: endocrine and metabolic relationships during abdominal aortic surgery. Anesthesiology 1989;71:355-361

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