Resuscitation
Scott F. Reed, MD, FACS
Resuscitation

Blood – Greeks
– One of the 4 essential humors
– Contained your “vital essence.”

Always a point of confusion
– Mental illness (bad humor) – take the
blood out
– Swelling / inflammation – blood letting
Resuscitation

1628 – William Harvey
– Described the anatomy of the circulatory
system (closed system)
– Maybe we should try to keep the blood in
the system
Resuscitation
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1665 – Richard Lower – transfused
blood between two animals
1667 – Jean-Baptist Denis –
transfused lambs blood into a patient
with mental illness
1668 – British Royal Society – banned
transfusions
1669 – France and the Vatican
followed
And that was the end of that…
Resuscitation
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
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1818 – James Blundell – Successful
human-to-human transfusion
1901 Karl Landsteiner (Vienna)
discovered the ABO system
1915 Lewinsohn (Mt. Sinai hosp, NY)
added citrate and glucose (could now
store blood for about 2 weeks)
Resuscitation

1832 Thomas Latta (Scottish) and
William Brook O’Shaughnessy (Irish)
– Working on Cholera
– Saline solutions to restore the specific
gravity of the blood
History


1883 – Sidney Ringer – found that
frog hearts perfused with New River
Water Co. (City water) lasted longer
than those perfused with distilled
water
– Proposed the calcium was the
difference
1934 Hartmann – added sodium
lactate and called it lactated Ringer’s
solution
Resuscitation

Walter Cannon
– Used 4% saline as war-time resuscitation
fluid
– 1918 “If the pressure is raised before the
surgeon is ready to check any bleeding
that may take place, blood that is sorely
needed may be lost.”
Problem
Problem
Most of our resuscitation is based
on fluids from the last century
(in a fancy new bag)
Resuscitation

What you want
– Reversal of shock state (restoration of
cellular perfusion)
– Maintenance of blood / fluid volume to
ensure adequate hemodynamics
– Maintenance of coagulation factors
– Prevent hypothermia / hypocalcemia
– Way to follow your progress (are we
making ground or falling behind?)
Resuscitation

What you DON’T want
– Fail to meet metabolic demands
– Increase ongoing bleeding
– Dilute coagulation factors
– Over or under resuscitate the patient
Resuscitation
Goldilocks theory

Too little…
–
–
–
–
Ongoing shock
Continued acidosis
Coagulopathy
Myocardial
dysfunction
– Renal failure
– Shock liver
– Death

Too much…
– Increased bleeding
(disruption of clot)
– Dilution of
coagulation factors
– Compartment
syndromes
– Transfusion related
problems


Inflammation /
immunosuppression
TRALI
Disclaimer

Wars have been waged over less
controversial issues than resuscitation.
– There is no perfect fluid
– There is no perfect measure / end point
– There is enough variability as to make
studying the problem very difficult
Resuscitation

Shock (What type of problem)
– Hemorrhagic (trauma, AAA, GI bleed)
Tank is leaking and becoming empty
 Solution: Fix the hole(s)

– Sepsis
Blood / Fluid level may be OK but the tank is
too big. (shunting and mitochondrial
dysfunction)
 Solution: Fix the source of infection

Damage Control Resuscitation
Resuscitation

Concepts to discuss
– Hypotensive resuscitation
– Small volume resuscitation
– Blood product ratios
– Autotransfusion
– End points of resuscitation
Then we can discuss some articles that actually
support (and some that refute) the position so you
don’t think that I’m making this stuff up.
Resuscitation

So what about this lecture???
– It is NOT a lecture (lectures are boring
and reserved for our children.)
– This is an exchange of ideas so please
ask questions.
– You won’t be a convert to any of this
because the data is shaky, and the
concepts will change.
Hypotensive Resuscitation



Idea that the higher the blood
pressure, the faster the bleeding
Higher pressures will disrupt newly
forming clot
Not a new idea
Hypotensive Resuscitation

What is done
– Maintain a lower BP until the bleeding is
controlled – Then increase rate / volume
of resuscitation.

Questions
– How low is too low?
– How long can the lower MAP be
maintained?
Hypotensive Resuscitation
Hypotensive Resuscitation
On arrival
Acid base standpoint – about the same
Hemoglobin / coagulopathy - better to wait
NEJM Oct 27, 1994, Vol. 331 No. 17
Hypotensive Resuscitation
Before OR
2.6 liters vs 386ml
Overall Crystalloid
9,250
6,904
NEJM Oct 27, 1994, Vol. 331 No. 17
Hypotensive Resuscitation
NEJM Oct 27, 1994, Vol. 331 No. 17
Hypotensive Resuscitation
NEJM Oct 27, 1994, Vol. 331 No. 17
Compared trauma patients that
has one SBP<90 who were
randomized to resuscitation to SBP
0f 100 vs 70.
J. of Trauma – Vol 52, #6
Hypotensive Resuscitation

Yeah, but that ATLS book says I have
to give 2 liters of LR to every trauma
patient who is hypotensive
Hypotensive Resuscitation

But…It seems that large volumes of
crystalloid may be detrimental.
– Pulmonary edema
– Compartment syndromes
– Dilution of coagulation factors
 Is
there a better way?
Small Volume Resuscitation
Using a hypertonic / hyperosmotic fluid that
will remain in the vascular space longer, with
less extravasation into the interstitium – thus
restoring vascular volume.



Hespan / Hetastend
Albumin
Hypertonic Saline (3% to 7.5%)
Small Volume
Resuscitation

Standard procedure in the military
– 7.5% saline / 6% hespan in a 250cc
bolus

Can’t logistically carry liters of fluid in the field
Hespan / Hetastend

Large carbohydrate molecule
– May cause coagulopathy in large doses
(30ml per Kg) in a 70kg person 2.1 liters
– Renal tubular dysfunction concern
Hetastarch
1,714 pts (805 hetastarch / 909 standard care)
85% of HET got 500cc / 15% got 1000cc
No difference in coagulopathy or urine outputs
Hetastarch in safe and effective in the doses used
JACS May 2010, Vol 210, No. 5
Hetastarch

500cc of hetastarch expands the blood
volume 800cc whereas it would take
approximately 3 liters of LR to do the
same
Hypertonic Saline
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3% saline
Longer intravascular half life and
expands blood volume 1:1.5
Better at reducing intra-cranial
pressures than mannitol
Doesn’t activate neutrophils like LR
Albumin

No good studies that look specifically
at using albumin in a resuscitation
setting.
– S.A.F.E. trial (getting kind of old – didn’t
use very high volumes in any comparison
group) – no difference between saline
and albumin in ICU patients
Small Volume Resuscitation
The Cochran Library – 2009 Issue #3
The Moral of the Story
The Cochran Library – 2009 Issue #3
Blood Product Ratios

Acute Coagulation of Trauma Shock
(ACoTS)
– Classic “lethal triad”
Coagulopathy
 Acidosis
 Hypothermia

– Loss, dilution and dysfunction
Loss – factors are consumed
 Dilution – transfused with non-factor fluids
 Dysfunction – protease due to acidosis / cold

Frith, D, Brohi,K The Acute Coagulopathy of Trauma Shock
– Clinical Relevance. Surgeon, 2010 #8 (159-163)
Blood Product Ratios

7 Year retrospective trial
– 435 emergency surgeries with over 10 units PRBC’s
– 135 with trauma induced coagulopathy (INR > 2,
PT> 16, PTT>50sec) and 53 died (39.5%)
Journal of Trauma July 2009 Vol 67, No1
Blood Product Ratios

Looking at the ratios of PRBC’s to FFP
in those with TIC
– 1:1 vs 1:4

Mortality 28.2 vs 51.1
– 1:2 vs 1:3

Mortality 38% vs 40%
Journal of Trauma July 2009 Vol 67, No1
Blood Product Ratios

Problems
– Small sample
– Did the most severely injured pt’s get blood,
then die while the FFP was thawing?
– Other studies don’t show the same advantage
Blood Product Ratios
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32 patients
Transcutaneous probe on thenar eminence
one hour before and 4 hours after
transfusion
Two groups (old blood over 21 days and
new blood less than 21 days old)
Journal of Trauma July 2009 Vol 67, No1
Blood Product Ratios
Autotransfusion

Perfect resuscitation fluid
– Perfect antigen match
– Carry oxygen
– Low cost

Military
– “walking blood bank” – personnel are typed
beforehand and donate as needed so pt gets
fresh whole blood
Autotransfusion

Typically red cells are separated from
plasma, “washed”, then concentrated
and given back to the patient as
PRBC’s
– What does it really cost?
– Does it decrease donated PRBC use?
– What about contamination?
Autotransfusion
Using a cell saver
47 control / 47 in cell saver group (avg 819ml of blood)
Cell saver group:
less intra-op donated blood (2 vs 4 units)
less total blood (4 vs 8 units)
less plasma (3 vs 5 units)
Cost of blood products ($1616 vs $2584)
Arch Surg – Vol 145 (No 7) July 2010
Autotransfusion

No increase in infectious complications
Arch Surg – Vol 145 (No 7) july 2010

Several articles where contaminated
blood was used – no increase in
infections
Timberlake, GA, McSwain, NE Autotransfusion of blood
contaminated by enteric contents: a potentially life-saving
measure in the massively hemorrhaging trauma patient?
J of Trauma 1988: 28(6): p855
Autotransfusion

Direct transfusion of whole blood
– From chest tubes – done with special
pleura-vac with a port to withdraw blood
from the collection chamber
– From abdominal cavity
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More to follow
End Points of Resuscitation
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How do I know where I’m at?
– How long have they been down?
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How do I know how I’m doing?
When am I done doing it?
End Points of Resuscitation
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CVP and Swan-Gantz Catheters.
– Not predictive of fluid responsiveness
– Values affected by
Intra-abdominal pressures
 Intra-thoracic pressures (PEEP, PIP)

End Points of Resuscitation
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Base deficit – easy and fast
Lactate – easy but takes awhile to get
results
Mixed venous saturation – requires
special lines and equipment but gives
a continuous reading
End Points of Resuscitation

Base deficit
– Retrospective study to see who dropped
their BP’s a second time after being
hypotensive in the field but arriving
normotensive (crumped)

5 year period – 231 patients hypotensive in
field but normotensive on arrival – 189 had
BD’s
Bilello, JF et. al. Prehospital Hypotension in Blunt
Trauma: Identifying the “Crump Factor.” Journal of
Trauma. Dec 4, 2009 Epub.
End Points of Resuscitation

Base Deficit
– Of the 189 patients

Base deficit of < or = to -6
– Repeat hypotension 78% vs 30%

Repeat hypotension
– Mortality of 24% vs 5%
Bilello, JF et. al. Prehospital Hypotension in
Blunt Trauma: Identifying the “Crump Factor.”
Journal of Trauma. Dec 4, 2009 Epub
So, what do I do…

Alpha trauma
– All get an ABG and serum lactate on
arrival

Base deficit over 6 causes concern.
– Hypotension

SBP in 80’s – 500cc of 3% hypertonic saline
– Head injury

Even a suspicion get hypertonic
So, what do I do…

Quick to find source of bleeding
– If chest – chest tube with rapid
autotransfusion of output
– Abdomen – (FAST ultrasound) then
quickly to OR (cell saver if time)
– Colley Ave. – Source control

HTS, 1-2 liters of LR then to blood
– If more than 3-4 units of blood, then FFP
So, what do I do…


In my head I’m counting crystalloid
Pressure bag and a cordis can be trouble,
especially if we go to CT.
– I don’t want more than 2-3 liters before OR
– OK to have SBP in 80-90’s (especially if talking)
– OK to use some hespan (500-1000cc) in work-up
and in OR
So, what do I do…
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In the OR I try to tell anesthesia if we are
still bleeding and when we have it stopped
Hopefully by this time the FFP is thawed
and can start to catch up to 1:1
If pt is unstable I give myself 1 hour on
the clock to get out of OR
– Blue towel closure
– Upstairs to BTU
– Come back to fight later