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16/10/10 1 Forfatter Prosjektittel

FORSVARET Forsvarets logistikkorganisasjon

16/10/10 1

NORWEGIAN ARMED FORCES Norwegian Armed Forces Medical Services

Health for fighting strength

Crystalloids and colloids in RDCR

Christian Medby Anaestesiologist

Norwegian Armed Forces Medical Services

& St Olav University Hospital

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What is Remote DCR?

•  Far forward •  Prehospital •  No/limited surgical capability

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What is Remote DCR?

•  Life-saving interventions •  Use of hemostatic agents •  Blood transfusions •  Hypotensive fluid resuscitation

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”Lethal triad” Coagulopathy Hypothermia

Acidosis

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•  Very little room for colloids and crystalloids in RDCR

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In fact, most clinical evidence suggests that we are better off giving no fluids..

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”For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until

operative intervention improves the outcome.”

Bickell, W. H., Wall, M. J., Pepe, P. E., Martin, R. R., Ginger, V. F., Allen, M. K., & Mattox, K. L. (1994). Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New Eng J Med, 331(17), 1105–9

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5

Prehospital Intravenous Fluid Administra5on Is Associated With Higher Mortality in Trauma Pa5ents: A Na5onal Trauma Data Bank Analysis. Haut, Ellio,; Kalish, Brian; Co,on, Bryan; MD, MPH; Efron, David; Haider, Adil; MD, MPH; Stevens, Kent; MD, MPH; Kieninger, Alicia; Cornwell, Edward; Chang, David; MBA, MPH Annals of Surgery. 253(2):371-‐377, February 2011. DOI: 10.1097/SLA.0b013e318207c24f

MulUple logisUc regression showing odds raUo of death for trauma paUents with prehospital IV fluid administraUon-‐subset analyses.

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”The review found no evidence to suggest that prehospital IV fluid

resuscitation is beneficial, and some evidence that it may be harmful.”

Dretzke J, Sandercock J, Bayliss S, Burls A. Clinical effectiveness and cost-effectiveness of prehospital intravenous fluids in trauma patients. Health Technol Assess 2004;8(23).

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•  Restrict prehospital fluid resuscitation in patients with a radial pulse and normal mental status

•  Hypotension, coagulation and vasospasm will limit blood loss

Hypotensive fluid resuscitation

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The concept of hypotensive resuscitation is extrapolated from ‘delayed resuscitation’ and mostly supported by animal studies

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Mor

talit

y

Amount of fluid infused

HAHN, R. G. (2012). Fluid therapy in uncontrolled hemorrhage - what experimental models have taught us. Acta Anaesthesiologica Scandinavica, 57(1), 16–28.

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”Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality

in this study.”

Dutton, R. P., Mackenzie, C. F., & Scalea, T. M. (2002). Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma, 52(6), 1141–6.

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”Hypotensive resuscitation is a safe strategy for use in the trauma population and results in a significant reduction in blood product transfusions and overall IV fluid administration. (…) lowers the risk of early postoperative death and coagulopathy.” Morrison, C. A., Carrick, M. M., Norman, M. A., Scott, B. G., Welsh, F. J., Tsai, P., et al. (2011). Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma, 70(3), 652–63.

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Colloids or crystalloids?

Blood

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Crystalloids/colloids vs blood

Blood: • Expands blood volume • Risk of transmission of pathogens • Transports oxygen • Contains platelets and coagulation factors

Crystalloids/colloids • Expands blood volume • No risk of disease transmission • No oxygen carrying capacity • Dilutes platelets and coagulation factors

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Crystalloids or colloids? •  Colloids have the advantage of staying

longer in circulation •  Less colloids needed for same expansion

of intravascular volume •  Colloids cause less edema

However…

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Colloids cause coagulopathy

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Sorensen, B., & Fries, D. (2011). Emerging treatment strategies for trauma-induced coagulopathy. Br J Surg, 99(S1), 40–50.

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Comparisons of lactated Ringer’s and Hextend resuscitationon hemodynamics and coagulation following femur injury

and severe hemorrhage in pigs

Wenjun Z. Martini, PhD, Michael A. Dubick, PhD, and Lorne H. Blackbourne, MD, Fort Sam Houston, Texas

BACKGROUND: This study compared coagulation function after resuscitation with Hextend and lactated Ringer’s (LR) solution in pigs with tissue injuryand hemorrhagic shock.

METHODS: Pigs were randomized into control (n = 7 each), LR, and Hextend groups. Femur fracture was induced using the captive bolt stunner atmidshaft of the pigs’ left legs, followed by hemorrhage of 60% total blood volume and resuscitation with either Hextend (equal to bledvolume) or LR to reach the same mean arterial pressure. Pigs in the control group were not bled or resuscitated. Hemodynamics wasmonitored hourly for 6 hours. Blood samples were taken at baseline (BL), after hemorrhage, 15 minutes, 3 hours, and 6 hours afterresuscitation for blood and coagulation measurements.

RESULTS: Mean arterial pressure decreased to 50% of BL by the 60% hemorrhage but returned to near BL within 1 hour after LR or Hextendresuscitation. Heart rate was increased (from 91 T 4 beats per minute to 214 T 20 beats per minute) by hemorrhage and decreased afterresuscitation but remained elevated above BL in both groups. Resuscitation with Hextend (42 mL/kg) or LR (118 T 3 mL/kg) reducedhematocrit, total protein, fibrinogen, and platelet counts, with greater decreases shown in the Hextend group. Clot strength was lower butreturned to BL by 3 hours in the LR group, whereas it remained reduced for the 6-hour period after Hextend. The overall clottingcapacity after LR was decreased after hemorrhage and resuscitation but returned to BL by 3 hours, whereas it remained low afterHextend for the 6-hour experiment period.

CONCLUSION: After traumatic hemorrhage, coagulation function was restored within 6 hours with LR resuscitation but not with Hextend. The lack ofrecovery after Hextend is likely caused by greater hemodilution and possible effects of starches on coagulation substrates and furtherdocuments the need to restrict the use of high-molecular-weight starch in resuscitation fluids for bleeding casualties. (J Trauma AcuteCare Surg. 2013;74: 732Y740. Copyright * 2013 by Lippincott Williams & Wilkins)

KEY WORDS: Hemorrhagic shock; Hextend; lactated Ringer’s (LR) solution; thrombelastography; pig.

Hemorrhage is the leading cause of potentially survivabledeath in the battlefield and amajor cause of death in civilian

trauma.1 Blood loss is also commonly encountered during sur-gical intervention.2 To restore tissue perfusion and hemody-namics, fluid resuscitation is a routine clinical practice to treathypovolemia. A variety of resuscitation fluids have been usedaround the globe, with selections depending on availability, cost,and clinical experience.3 Crystalloids, such as isotonic sodiumchloride solution and lactated Ringer’s (LR) solution, are inex-pensive and have been widely used at prehospital and hospitalsettings. Colloids, such as albumin, gelatin, and hydroxyethylstarch (HES), are highly effective in increasing intravascularvolume with small volume increase in interstitial space (com-pared with crystalloids). Different colloid products have beenused in clinical practice.4Y7As one of theHESproducts, Hextend

(BioTime, Berkeley, CA) was developed and approved for use asa plasma volume expander in the United States in 1999 and wasrecommended for use in the military by the committee on Tac-tical Combat Casualty Care.8 It contains 6% hetastarch with amean molecular weight (MW) of 670 kD and a degree ofhydroxyethyl group substitution of 0.75 (HES 670/0.75) in aphysiologically balanced solution of electrolytes, glucose, andlactate. The newest starch product,Voluven (FreseniusKabi, BadHomburg, Germany), was developed and approved in Europeand recently in the United States and contains 6% Hetastarchwith a MW of 130 kD and a degree of hydroxyethyl groupsubstitution of 0.4 (HES 130/0.4) in saline medium. A growingnumber of studies have been undertaken to investigate resusci-tative effects of colloids.5,6,9Y14 Although effective volume ex-pansion and positive clinical outcomes have been reported inclinical trials and animal studies,7,15Y16 colloid infusion has beenshown to be associated with reductions of coagulation factors,17

platelet dysfunction,18Y20 anaphylactic reactions,21 and hemor-rhagic complications.22Y24

Limited information is available comparing Hextend withcrystalloid LR after hemorrhage in vivo. In a swine model, Toddet al.25 investigated effects of LR and Hextend on coagulationchanges and blood loss after severe liver injury. However, sincethe only coagulation data shown were at the end of the study,25

it is difficult to evaluate the time course changes in coagula-tion from either LR or Hextend resuscitation or compare theeffects between LR andHextend from that study. In patients who

AAST 2012 PLENARY PAPER

J Trauma Acute Care SurgVolume 74, Number 3732

Submitted: September 20, 2012, Revised: November 14, 2012, Accepted: November20, 2012.

From the US Army Institute of Surgical Research, Fort Sam Houston, Texas.This study was presented at the 71st annual meeting of the American Association

for the Surgery of Trauma, September 12Y15, 2012, in Kauai, Hawaii.The opinions or assertions contained herein are the private views of the authors and

are not to be construed as official or as reflecting the views of the USDepartmentof the Army or the US Department of Defense.

Address for reprints: Wenjun Z. Martini, PhD, US Army Institute of Surgical Re-search, 3698 Chambers Pass, Fort Sam Houston, TX 78234; email: [email protected].

DOI: 10.1097/TA.0b013e31827f156d

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Dextran > HES > Gelatins

Dextran: platelet dysfunction (acquired von Willebrand’s state)

HES: coating of platelets Gels: impaired fibrinogen polymerization

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2

Crystalloids vs. colloids in fluid resuscita5on: A systema5c review. Choi, Peter; MD, FRCPC; Yip, Gordon; Quinonez, Luis; Cook, Deborah; MD, FRCPC CriUcal Care Medicine. 27(1):200-‐210, January 1999.

Effect of crystalloids vs. colloids on mortality in trauma paUents.

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Colloids

Conclusions: Overall, there is no apparent difference in pulmonary edema, mortality, or length of stay between isotonic crystalloid and colloid resuscitation. Crystalloid resuscitation is associated with a lower mortality in trauma patients. Methodologic limitations preclude any evidence-based clinical recommendations. Larger well-designed randomized trials are needed to achieve sufficient power to detect potentially small differences in treatment effects if they truly exist.

(Crit Care Med 1999;27:200-210)

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Colloids versus crystalloids for fluid resuscitation in criticallyill patients (Review)

Perel P, Roberts I

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2012, Issue 11

http://www.thecochranelibrary.com

Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review)

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.

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Hypertonic saline Hypertonic resuscitation of hypovolemic shock after blunt

trauma: a randomized controlled trial.

Bulger EM, Jurkovich GJ, Nathens AB, Copass MK, Hanson S, Cooper C, Liu PY, Neff M, Awan AB, Warner K, Maier RV.

Arch Surg. 2008 Feb;143(2):139-48; discussion 149.

…stopped for safety reasons

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My opinion:

The only reason to choose colloids is logistical: less volume, less weight.

Choose colloids if you have to carry it

yourself.

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What about crystalloids?

•  Edema •  ARDS •  Hyperchloraemic acidosis (NS) •  Compartment syndromes •  Dilution coagulopathy

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What crystalloid?

•  ‘Balanced’ crystalloids cause less hyperchloraemic acidosis

•  Less electrolyte disturbances

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What are the alternatives?

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Blood?

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Thrombin generation after dilution. Thrombin generation patterns in platelet-poor plasma are shown before and after dilution to about 40% of baseline. The patterns are similar between baseline and dilution with fresh frozen plasma (FFP).

33

Bolliger, D., Görlinger, K., & Tanaka, K. A. (2010). Pathophysiology and treatment of coagulopathy in massive hemorrhage and hemodilution. Anesthesiology, 113(5), 1205–19.

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Hess JR et al. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008 Oct;65(4):748-54.

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Questions?

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