waldemar machała principles of fluid therapy in a massive trauma and hemorrhage. department of...
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Waldemar Machała
Principles of fluid therapy in a massive trauma and hemorrhage.
Ghazni, Afghanistan, September 2012
Department of Anesthesiologyand Intensive Care
The Military Teaching Hospital-CSW
The gen. bryg. Stefan Hubicki Military Center of Medical Education
Estimated blood volume (EBV)
Age Volume (mL/KG)
Premature 100
Newborn 90
Pre-school 80
School-age 75
Adult 70
Hematocrit – 40%Hematocrit RBC (PRBC) – on average approx. 60%
Miller’s Anesthesia, 7th edition. 2010: chapter 82.A practice of anesthesia for infants and children, 4th edition: chapters 8 and 10. C Cote. 2009.
Loss of 1.5 mL of blood/KG/min. for 20 mins.
Loss of 150 mL of blood/min. within 1 hr.
Transfusion of 50 % of circulating blood volume within 3 hrs.
Transfusion of one volume of circulating blood within 24 hrs.
Hemorrhage / transfusion
Keel M et al: Pathophysiology of trauma. Injury 2005; 36: 691-671.
Shock
1. Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, 1972. Plenum Press.2. Rodriguez RM, Rosenthal MH: Etiology & Pathophysiology of shock. W: Murray MJ, Coursin DB, Pearl RG, Prough DS. eds. Critical care medicine - Perioperative management.
Lippincott William & Wilkins, London. 2003; 192-205.
State of inadequate oxygen supply to cells University of Wisconsin Department of Surgery.
Circulatory collapse National Institute of General Medical Sciences.
Hypovolemic.
Obstructing.
Cardiogenic.
Distributive.
Hypovelemic shock Hinshaw, Cox 1972
Hemorrhagic.
Visible.
Invisible.
Non-hemorrhagic.
1. Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, 1972. Plenum Press.2. Rodriguez RM, Rosenthal MH: Etiology & Pathophysiology of shock. W: Murray MJ, Coursin DB, Pearl RG, Prough DS. eds. Critical care medicine - Perioperative management.
Lippincott William & Wilkins, London. 2003; 192-205.
Blood loss resulting from bodily injuries
Lung:1000 mL (each side)
Liver:2000 mL
Pelvis:>5000 mL
Thigh:2000 mL
Crus:1000 mL
Arm:800 mL
Spleen:2000 mL
Forearm:400 mL
Basics for fluids tranfusion after the trauma
1. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.
O2 flow = [CO X Hgb X SaO2 X k] + [CO X PaOa x 0.003]
The quickest possible restoration of tissue oxygenation.
Causing the smallest possible biochemical abnormalities.
Protection of renal functions.
Avoiding fluids transfusion-related complications.
Time for fluid therapy onset
1. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.
Pre-hospital.
Hospital emergency ward.
During emergency operations.
In ICU.
On-site activities US Army
Physical status Conduct
Hemorrhage stopped with no symptoms of shock
No fluids transfusion
Hemorrhage stopped with symptoms of shock
HAES (Hespan) – 1000 mL
Uncontrollable hemorrhage (internal): abdomen, chest
No fluids transfusion
Wilson WC, Grande CM, Hoyt DB in: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Healthcare USA. 2007.
Scoop and run.
Stay and play (stay and treat).
On-site strategy of handling the injured
Basic life-saving actions
Advanced life-saving actions
Spine immobilization.Fractures immobilization.Dressing external hemorrhage.Bag mask ventilation.
Final securing of the airways.Decompression of pneumothorax.Coniotomy/ tracheotomy.IV access and fluids transfusion.
1. Berlot G, Bacer B, Gullo: Controversial aspects of the prehospital trauma care. Crit Care Clin 2006; 22: 457-468.2. Haas B, Nathens AB: Pro/con debate: is the scoop and run approach the best approoach to trauma services organization? Critical Care 2008; 12: 224 (http://ccforum.com/content/12/5/224.
In certain situations, starting rescue actions on site may prolong the time of definite life-saving actions onset1,2,3:
Attempts of artificial airways – instead of bag mask ventilation and transportation to the hospital.
Worse (adverse) result of therapy (next to statistically more frequent occurrence of coagulopathy and multiorgan failure) with the patients who were secured with vascular angioaccess and fluids transfusion and who:
Were diagnosed with penetrating bodily trauma4,5.
Were not secured as far as the hemorrhage site is concerned6.
On-site actions Scoop and run, or Stay and play?
1. Berlot G, Bacer B, Gullo: Controversial aspects of the prehospital trauma care. Crit Care Clin 2006; 22: 457-468.2. Haas B, Nathens AB: Pro/con debate: is the scoop and run approach the best approoach to trauma services organization? Critical Care 2008; 12: 224 (http://ccforum.com/content/12/5/224. 3. Bulger EM, Maier RV: Prehospital care of the injured: what’s new. Surg Clin North Am 2007; 87: 37-53.4. Bickell WH, Wall MJ Jr, Pepe PE i wsp.: Immediate vs delayed fluid resuscitation for hypotensive patients with penetrating torso injures. N Engl J Med. 1994; 331: 1105-1109.5. Ivatury RR, Nallathambi MN, Roberge RJ i wsp.: Penetrating thoracic injures: in-field stabilization vs prompt transport. J Trauma 1987; 27: 1073.6. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.
With the patients:
With no possibility of final (temporary) hemorrhage securing1,2,3:
Ectopic pregnancy.
Placenta previa.
Premature placental disruption.
Penetrating injuries (vascular injuries in 90%)4.
Internal hemorrhage.
In urban conditions.
In the circumstances when the ETA to the hospital is relatively short (4-12 mins.)5,6.
No attempts to cannulate the vessel or fluids transfusion should be made; instead:
The patient should be transported to the hospital a.s.a.p.
The hospital should be informed about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist).
On-site actions Scoop and run, or Stay and play?
1. Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26.2. Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204: 625-632.3. Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61: 1366-1372.4. Sanchez GP, Peng EWK, Marks R i wsp.: Scoop and run strategy for a resuscitative sternotomy following unstable penetrating chest injury. Interacive Cardiovasc Thorac Surg 2009; 10: 467-469.5. Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: 265-270.6. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.
With the patients with no possibility of final (temporary) hemorrhage securing1,2,3 no attempts to cannulate the vessel or fluids transfusion should be made, instead:
The patient should be transported to the hospital a.s.a.p..
The hospital should be informed about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist).
On-site actions Scoop and run, or Stay and play?
1. Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26.2. Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204: 625-632.3. Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61: 1366-1372.
Adverse effects of fluids transfusion with the lack of securing the hemorrhage site:
Increased bleeding from damaged vessels.
Smaller clot-forming abilities in the site where the vessels are damaged.
Increase in the hematocrit and the hemoglobin levels.
Lowering of the clotting factors levels.
Risk of hypothermia.
On-site actions Scoop and run, or Stay and play?
1. Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26.2. Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204: 625-632.3. Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61: 1366-1372.
With the patients whose hemorrhage was temporarily secured, e.g. by applying:1,2,:
Pressure dressing.
Tourniquet.
Polymer dressing (e.g. Quick-Cloth).
you should:
Secure two peripheral vascular angioaccess points (14G).
Apply infusion of 0.9% NaCl, or lactatad Ringer’s solution (1000 mL) – if SAP< 90 mm Hg (or 110 mm Hg – cerebral injuries).
Maintain MAP: 40-50 mm Hg.
In acute hypovolemia pathophysiology, decrease in preload prevails – hence, the only purposeful action is intravascular volume replacement.
Catecholamines increase afterload and are not recommended at this stage of shock.
Transport the patient to the hospital.
Inform the hospital about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist).
On-site actions Scoop and run, or Stay and play?
1. Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: 265-270.2. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.3. Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.
With the patients whose hemorrhage was temporarily secured, e.g. by applying:1,2,:
Pressure dressing.
Tourniquet.
Polymer dressing (e.g. Quick-Cloth).
You should:
Secure two peripheral vascular angioaccess points (14G).
Apply infusion of 0.9% NaCl, or Ringer’s solution (1000 mL) – if SAP< 90 mm Hg (or 110 mm Hg – cerebral injuries).
Keep MAP: 40-50 mm Hg.
In acute hypovolemia pathophysiology decrease of preload prevails – hence, the only purposeful action is intravascular volume replacement.
Catecholamines increase afterload and are not recommended at this stage of shock.
Transport the patient to the hospital.
Inform the hospital about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist)..
On-site actions Scoop and run, or Stay and play?
1. Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: 265-270.2. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.3. Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.
Watch out for: Pain. lactatedPsychomotor agitation.
(result of hypoxia)
On-site actions Scoop and run, or Stay and play?
1. Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: 265-270.2. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.3. Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.
On-site actions US Army
Physical status Action
Hemorrhage stopped with no symptoms of shock
No fluids transfusion
Hemorrhage stopped with symptoms of shock
HAES (Hespan) – 1000 mL
Uncontrollable hemorrhage (internal): abdomen, chest
No fluids transfusion?
In such circumstances, we may:
Allow for hypotension +/- ?.
Avoid hemorrhage volume increase.
Consider small volume resuscitation (SVR).
1. Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA. 2007.2. Rekomendacje dla podawania stężonej soli w HAES w NATO - http://ftp.rta.nato.int/public/Pubfulltext/RTO/MP/RTO-MP-HFM-109///MP-HFM-109-07.pdf
Alternative in fluid therapy?
1. Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscytation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA. 2007.2. Rekomendacje dla podawania stężonej soli w HAES w NATO - http://ftp.rta.nato.int/public/Pubfulltext/RTO/MP/RTO-MP-HFM-109///MP-HFM-109-07.pdf
?
On-site actions hemorrhage stopped but co-existing shock
HyperHAES because:
Instant increase of arterial blood pressure and cardiac output, with decreased systemic vascular resistance (SVR).
Instant microcirculation flow increase.
Lowering adverse effects of ischemia and reperfusion.
Increase of diuresis resulting from improved organ perfusion.
Increase in survival ratio.
Kreimeier i Messmer – experimental and clinical studies.
HyperHAES
…
HyperHAES → 6% HAES (200/ 0.5) + 7,2% NaCl → 250 mL bags.
Na+ 1232 mmol/ L.
Cl- 1232 mmol/ L.
pH 3.5 – 6.0.
Osmolarity: 2464 mOsm/ L.
COP 36 mm Hg.
Dosage: 4 mL/ KG (approx. 250 mL).
Infusion volume: 2 – 5 minutes.
HyperHAES - effects
…
Hypertonic solution of NaCl quickly increases circulating blood volume through transferring the fluid from extravascular to intravascular space.
7.2% NaCl included in the HyperHAES solution is responsible for inducing the mechanism of quick endogenous fluid transfer.
Colloid present in the solution binds water which ensures long-lasting volume effect.
Endogenous water is mobilized mainly from the area of erythrocytes and vascular endothelial cells:
Circulating blood volume is rapidly increased (3 – 4x of the transfused volume).
Microcirculation flow appears through endothelial cells dehydration thus increasing oxygen supply to tissues.
Ideal solution for fluid resuscitation:
…
Transfusion of small volume improves perfusion.
Beneficial effect on oxygen extraction in tissues:
Oxygen supply.
Oxygen use.
Proper composition taking into account pH measure and electrolyte composition.
Sterility.
Suitably long effects.
Stability.
Ready to use.
Inexpensive.
Crystalloids
…
mEq/ L
Type of solution Na+ K+ Cl- Base Ca2+ Mg2+ pH kcal/ l Osmolarity
ECF (plasma) 138 5 108 27 5 3 7.4 12 Isotonic
5% glucose - - - - - - 4.5 200 Hypotonic
Jonosteril Basic 49.1 24.9 49.1 10 - 2.5 4.5-5.5 200 Hypertonic
10% glucose - - - - - - 4.5 400 Hypertonic
0.9% NaCl 154 - 154 - - - 6.0 - Isotonic
Lactated Ringer’s solution
130 4 109 28 3 - 6.5 - Isotonic
Ringer’s solution in 5% glucose
130 4 109 28 3 - 200 Hypertonic
PWE 140 4 106 45 2.5 1 4.5-7.5 Isotonic
Sterofundin 140 4 106 45 2.5 1 - Isotonic
Colloids
…
Plasma Hemohes – 6%
Voluven(Fresenius-Kabi)
Tetraspan(BBraun)
Volulyte(Fresenius-Kabi)
Hextend(Hospira) – pH: 5.9
Na+ (mmol/ L) 142 154 154 140 137 143
K+ (mmol/ L) 4.5 - - 4 4 3
Ca2+ (mmol/ L) 2.5 - - 2.5 - 5
Mg2+ (mmol/ L) 0.85 - - 1 1.5 0.9
Cl- (mmol/ L) 103 154 154 118 110 124
HCO3-(mmol/ L) 24 - - - - -
Lactate (mmol/ L) 1.5 - - - - 28
Acetate (mmol/ L) - - - 24 34 -
Malate (mmol/ L) - - - 5 - -
Osmolarity (mOsm/ L)
295 310 308 296 286.5 307
Colloid (g/ L) Protein 30-52 Starch 60 Starch 60 Starch 60 Starch 60
Crystalloids vs. colloids volume effect
…
Transfused volume[mL]
Type of infusion fluid Increase in plasma volume
[mL]
1000 5% glucose 100
1000 Lactated Ringer’s solution
250
250 7,5% NaCl 1000
500 5% Albumins 375
100 25% Albumins 450
500 Volulyte 500
Time to start fluid therapy
1. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.
Pre-hospital.
Hospital emergency ward.
During emergency operations.
In ICU.
Recognize the shock paying attention to possible problems:
Co-existing CNS injury.
Age.
Body build (athletic).
Medication taken.
Hypothermia.
Pacer.
Clothes (waterproof; Velcro).
Hospital activities
1. Isenberg D: Does advanced life support provide benefits to patients? A literature review. Prehosp Disast Med. 2005; 20: 265-270.2. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.
Stop the bleeding – great ‘five’ of hemorrhages:
External:
Clinical examination.
BP monitoring.
Chest:
Clinical examination and chest X-ray.
Pulmonary drainage.
Abdomen:
Clinical examination.
DPO, FAST, CT, laparoscopy, laparotomy.
Pelvis:
Clinical examination.
X-ray, CT, angiography.
Long bones.
Hospital activities US Army
Rescue actions depending on response to fluid resuscitation (to fast transfusion):
2000 mL of lactated Ringer’s solution (adults).
20 mL/KG of lactated Ringer’s solution (children).
Changes Quick response Temporary response Lack of reaction
Vital functions Return to correct values Temporary improvement after which ↓BP and ↑HR
Incorrect values maintained
Estimated blood loss 10-20% 20-40% >40%
Necessity to infuse larger volume of crystalloids
Hardly possible Highly probable Highly probable
Necessity to transfuse blood Hardly possible Likely Necessary
Necessity to transfuse blood components
Hardly possible Highly possible Necessary transfusion in emergency mode
Necessity for the surgical intervention
Possible Probable Necessary
Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA. 2007.
Purpose of fluid therapy US Army
Concerns exclusively young and healthy people without co-existing CNS injury.
Early resuscitations ends with final securing of the hemorrhage spot.
Parameter Early purpose Late purpose
SAP 90 mm Hg > 100 mm Hg
HR < 120/ min. < 100/ min.
Hct > 25% > 20%
Lactates Values lower than those after the first examination
Normal
CO Dependant upon arterial blood pressure Possibly high
RKZ No respiratory acidosis.Permitted metabolic acidosis
Normal
Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Heathcare USA. 2007.
Platelet count:
<50 000 2 pts.
50 – 100 000 1 pt.
Fibrinogen:
< 1g/L 1 pt.
D-dimers:
> 4 mg/L 3 pts.
0.39-4 mg/L 2 pts.
INR:
>2,3 2 pts.
1.4-2.3 1 pts.
DIC and ACoTS criteria 1,2
1. Johansson PI, Sorensen AM, Perner A i wsp.: Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study. Critical Care 2012; 15: 272-285.2. Taylor FB, Jr, Toh CH, Hoots WK i wsp.: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001; 86: 1327-1330.
Criteria for diagnosing DIC:
≥ 5 pts.
Criteria for diagnosing acute coagulopathy of traumatic stress (ACoTS):
APTT or/and INR:
>35 secs. or 1.2.
Coagulopathy (on-site/ in the hospital)4,5,6:
Acute coagulopathy of traumatic stress (ACoTS).
Disseminated intravascular coagulation (DIC).
Because coagulation disorders appear as a result of:
Hemorrhage.
Traumatic stress.
And are worsened:
Resulting from physical status (co-existing illnesses).
After infusion of 2000 mL of fluids.
And are further increased in the course of:
Hypoperfusion with all its consequences.
Hypothermia.
Acidosis.
Hypercatecholaminemia.
Electrolyte imbalance.
Why is the discussion about DIC and ACoTS so important? 1,2,3
1. Johansson PI, Sorensen AM, Perner A i wsp.: Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study. Critical Care 2012; 15: 272-285.2. Taylor FB, Jr, Toh CH, Hoots WK i wsp.: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001; 86: 1327-1330.3. Shaz BH, Winkler AM, James AB i wsp.: Pathophysiology of early trauma-induced coagulopathy: emerging evidence for hemodilution and coagulation factor depletion. J Trauma 2011; 70: 1401-1407.
Monitoring clinical indicators denoting proper perfusion
Marik PE, Monnet X, Teboul JL: Hemodynamic parameters to gouide fluid therapy. Annals of intensive care 2011; 1: 1. http://www.annalsofintensivecare.com/content/1/1/
Mean arterial pressure.
Perfusion pressure: cerebral and visceral:
State of consciousness.
Diuresis.
Capillary refill.
Peripheral perfusion (mottled skin).
Temperature of peripheral body parts (cold feet, hands).
Lactates concentration.
Gasometry (pH, BE, HCO3-).
Mixed venous oxygen saturation (SvO2).
CO2 partial pressure in mixed venous blood.
CO2 partial pressure in tissues (StCO2).
O2 partial pressure in muscles (StO2).
Blood transfusion
Miller’s Anesthesia, 7th edition. 2010: chapter 82.A practice of anesthesia for infants and children, 4th edition: chapters8 and 10. C Cote. 2009.
Indications for transfusion:
Ischemia, Hgb < 7 g/dL.
Hematocrit < 25%.
Elderly patients with co-existing cardiac disease.
Increased oxygen demand.
Maintained Hgb levels: 7-9 g/dL.
Loss of the circulating blood volume (EBV – estimated blood volume)
Hematocrit– 40%Hematocrit RBC (PRBC) – on average approx. 60%
Crucial transfusion parameters
Product name Dosage Transfusion result
Erythrocyte concentrate 10-15 mL/KG Hemoglobin 2-3 g/dL
Erythrocyte concentrate 1 unit Hematocrit by approx. 3%.
Thrombocyte concentrate 5-10 units Platelets 50 000 – 100 000/mm3
Fresh frozen plasma 10 – 15 mL/KG Coefficient 15-20%
Kryoprecipitate 1-2 units/KG Fibrinogen 60-100 mg/dL
Miller’s Anesthesia, 7th edition. 2010: chapter 82.A practice of anesthesia for infants and children, 4th edition: chapters 8 and 10. C Cote. 2009.
End of fluid resuscitationEffective oxygen therapy resulting in the increase of SpO2>97%.
Mechanical intubation and ventilation:
Protection of lower airways:
Resolving of oxygenation abnormalities (FiO2<60% with SpO2>97%).
Resolving of ventilation impairments (ETCO2<60 mm Hg).
Replenishment of circulating blood volume (colloids, crystalloids, blood products):
CVP approx. 20 cm H2O.
Hgb: 10-12 g/dL.
Positive result of implemented therapy (including catecholamines) resulting in:
HR within: 50-120/min.
MAP within: 70-110 mm Hg.
Increase in the value of ScvO2>65%.
Decrease in lactates concentration <2 mmol/L.
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