Standard Resuscitation Paradigm Crystalloid 3:1 Ratio Transient or - - PDF document

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Standard Resuscitation Paradigm Crystalloid 3:1 Ratio Transient or - - PDF document

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5/30/2013 Transfusion Ratios: Whats the Civilian Trauma Mortality Evidence? 100% 90% 80% Percentage of deaths 70% Hemorrhage COD 60% in 30-40% of 50% 40% early deaths 30% 20% 10% Rachael Callcut, MD, MSPH 0% Prehospital First

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SLIDE 1

5/30/2013 1

Transfusion Ratios: What’s the Evidence?

Rachael Callcut, MD, MSPH Assistant Professor of Surgery, UCSF

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Prehospital First 24 hours After 24 hours Percentage of deaths Hemorrhage CNS Other Data adapted from: Acosta, et al. J Am Coll Surg 1998 & Sauaia, et al. J Trauma 1995

Civilian Trauma Mortality

Hemorrhage COD in 30-40% of early deaths

The Old Days…

Class I Class II Class III Class IV Blood Loss (ml) <750 751-1500 1501-2000 >2000 % Blood Vol <15% 15-30% 30-40% >40% Pulse <100 >100 >120 >140 BP nl nl decreased decreased Pulse Pressure nl decreased decreased decreased RR 14-20 20-30 30-40 >35 UOP >30cc/hr 20-30 5-15 negligible CNS nl anxious confused lethargic Fluid Choice crystalloid crystalloid crystalloid crystalloid and blood and blood

Standard Resuscitation Paradigm

Crystalloid 3:1 Ratio Blood FFP

Transient or no response

6-10 u PRBC

Crystalloid

Goal:

“To restore intravascular volume & VS back to normal as quickly as possible to restore vital

  • rgan perfusion.”
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SLIDE 2

5/30/2013 2

Military Resuscitation Standard Resuscitation

  • Cochrane Review (2003)
  • No evidence to support large-volume I.V. fluid

resuscitation

But is it harmful?

  • Harmful effects:

– Increased BP accelerates rate of bleeding which can dislodge a soft early clot – Dilutes RBCs therefore reduces oxygen delivery despite an increased CO – Reduced hct and clotting factors inhibit new clot formation – Resuscitative fluids are harmful themselves

  • Acidic
  • Pro-inflammatory
  • Abdominal Compartment Syndrome

The consequence…

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SLIDE 3

5/30/2013 3

Lung Histology

Sham LR WB

Makley et al, J Trauma 2010

Acidosis Hypothermia

Coagulopathy

Death

Brohi, K, et al. J Trauma, 2003.

Lethal Triad

Base Deficit

Hypothermia

  • 18% arrive cold (<36°F)
  • 100% mortality <34°C
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SLIDE 4

5/30/2013 4

What Resuscitation Strategy for the Severely Injured? What are our goals?

  • Restore volume
  • Correct acidosis
  • Avoid coagulopathy
  • Avoid hypothermia
  • Blunt anemia

What is the solution? Warm Fresh Whole Blood

 Restore volume  Reverse acidosis  Avoid coagulopathy  Avoid hypothermia  Blunt anemia

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SLIDE 5

5/30/2013 5 How about reconstituted whole blood?

 Restore volume  Reverse acidosis  Avoid coagulopathy  Avoid hypothermia  Blunt anemia

Component Therapy vs. Fresh Whole Blood

PRBC Hct 55% 335 mL Plt 5.5x1010 50 mL FFP 80% 275 mL

Component Therapy

1U PRBC + 1U PLT + 1U FFP + 10 pk Cryo =

660 COLD mL

  • Hct 29%
  • Plt 87K
  • Coag activity 65%
  • 750 mg fibrinogen

500 mL Warm Hct: 38-50% Plt: 150-400K Coags: 100%

  • Armand & Hess, Transfusion Med. Rev., 2003

1500 mg Fibrinogen

Hemostatic (Damage Control) Resuscitation

  • Concept from Damage Control Surgery

– “Staying out of trouble rather than getting out of trouble”

  • Aggressive hemostatic resuscitation techniques should

be performed in parallel with equally aggressive surgical control of bleeding

J Trauma, 2007.

Damage Control Resuscitation

  • Goal is to avoid exsanguination and

coagulopathy

  • Uses pRBCs and FFP + platelets
  • Preliminary data from OIF/OEF
  • Civilian data compelling to make this

Standard of Care

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SLIDE 6

5/30/2013 6

Key Concepts of DCR

  • Recognize Shock

– Identify the critical 10 %

  • Resuscitate Immediately

– Devote attention to Hemostatic resuscitation

  • Provide volume that also

restores the hemostatic cascade

  • Minimize crystalloid
  • Stop the bleeding
  • Stay out of trouble

How do we do it?

Component Therapy What Transfusion Ratio??

  • Median ratio of FFP: RBC was 1:1.7 in

survivors compared to 1:3 in non-survivors (p<0.001). Cause of Death

Can we apply this to the Civilian Trauma Patient?

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SLIDE 7

5/30/2013 7

Civilian Literature (2008)

2746 pts needing operative intervention, 4yr retrospective study

  • Survivors vs. Non-Survivors

– FFP:PRBC ratios

  • Plasma rich (≥1u FFP : 1.5u PRBCs)
  • Plasma poor (< 1u FFP : 1.5u PRBCs)
  • OR death (multivariate logistic regression)

PRBC (mean +/- sd)

9.8 units +/- 11.7 1-80 units

FFP (mean +/- sd)

8 units +/- 7.6 0-37 units

FFP:PRBC (mean)

1 : 1.26 57% 1: 1.5 or better

Plasma rich (survival)

84%

Plasma poor (survival)

60% p=0.04

OR death (poor vs. rich)

3.57 (95% CI 1.02 – 12.5) p<0.05 Multicenter, retrospective 466 pts. Single center, prospective, 214 MT pts. Platelets: RBCs

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SLIDE 8

5/30/2013 8

16 Trauma centers pooled their one year experience with transfusion of trauma patients

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SLIDE 9

5/30/2013 9

Is all 1:1 the same?

pRBC FFP pRBC FFP pRBC FFP pRBC FFP pRBC FFP pRBC pRBC pRBC pRBC pRBC FFP FFP FFP FFP FFP

5 pRBC, 5 FFP 5 pRBC, 5 FFP

  • 10 Level 1 trauma centers
  • July 2009-October 2010
  • Primary objective:

– Investigate in hospital mortality in all patients surviving at least 30 minutes after ED admission

  • Minute to minute tracking until resuscitation

complete

  • Followed until hospital discharge

Prospective Observational Multicenter Major Trauma Transfusion study

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SLIDE 10

5/30/2013 10 Other Patient Population Who MAY Also Benefit?

Known

  • Trauma patients requiring

<10 units PRBCs (Sub MT)

  • Ruptured AAA
  • Emergency general surgery

patients Theoretic

  • Massive GI bleed
  • Cardiac Surgery
  • Major Orthopedic Cases
  • Vascular elective surgery
  • OB

PRBC 1 – 9 units PRBC 4 – 9 units

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SLIDE 11

5/30/2013 11

plasma 2:1 1:1 1:2 pRBCs Evans Blue (ug/g tissue) 2 4 6 8 10 12 14 plasma 2:1 1:1 1:2 pRBCs Evans Blue (ug/g tissue) 5 10 15 20

Colon Evan’s Blue Lung Evan’s Blue

Figure 4:. Evan’s blue levels in the colon after resuscitation. P<0.05 vs plasma alone

* *

Figure 5:. Evan’s blue levels after resuscitation in the lung. P<0.05 vs pRBCs alone

Is 1:1 the correct ratio?

plasma 2:1 1:1 1:2 pRBCs Concentration (pg/mL) 200 400 600 800 1000 1200 1400

MIP-2

Figure 1:. MIP-2 Levels after resuscitation. P<0.05 vs all other groups

*

plasma 2:1 1:1 1:2 pRBCs Concentration (pg/mL) 200 400 600 800

MIP-1α

Figure 2:. MIP-1α Levels after resuscitation. P<0.05 vs plasma and pRBCs alone

*

Makley et al, manuscript 2011

http://cetir-tmc.org/research/proppr

  • Phase III clinical trial
  • Investigating 1:1:1 plasma:platelet:pRBC vs.

1:1:2

  • 12 US trauma centers
  • Enroll 580 MT patients prospectively
  • Outcome 24 hr & 30 d mortality

Summary

  • Prospective Observational data supports prior

retrospective data that more balance plasma to PRBC to platelets improves survival in massively hemorrhaging trauma patients.

  • RCT is forthcoming for optimum ratio.
  • Overall number of units utilized is decreasing.
  • Many analogous hemorrhaging ICU patient

populations that may also benefit.

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SLIDE 12

5/30/2013 12

Acknowledgements

  • PROMMTT Investigators

– Univ of Cincinnati Department of Surgery – Univ of Texas – Houston – UCSF

  • PROPPR Investigators
  • Cohen Research Staff
  • 24/7 Staff
  • Mary Nelson, RN
  • Military Colleagues

Acknowledgements