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Fluid resuscitation of trauma patients: how fast is the optimal rate?

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Title: Fluid resuscitation of trauma patients: how fast is the optimal rate?


1
Fluid resuscitation of trauma patients how fast
is the optimal rate?
  • Yasuaki Mizushima MD, Hideo Tohira MD, Yasumitsu
    Mizobata MD,
  • Tetsuya Matsuoka MD, Junichiro Yokota MD
  • Osaka Prefectural Senshu Critical Care Medical
    Center, Osaka, 598-0048, Japan
  • American Journal of Emergency Medicine (2005) 23,
    833837
  • Presented by Intern Dr.???

2
1. Introduction
  • Rapid responders, transient responders, or
    minimal or nonresponders
  • Responders ? observed to identify those patients
    with ongoing bleeding requiring surgical control
  • Nonresponders ? immediate surgical intervention
  • Hypovolemic shock ? Tx
  • Arrest of bleeding
  • Replacement of circulating fluid volume.
  • Initial rapid fluid infusion as diagnostic
    procedure Recommendation of Advanced Trauma Life
    Support guidelines (6/e, American College of
    Surgeons, 1997)

3
1. Introduction
  • 1-2 L crystalloid infusion Recommended by the
    Advanced Trauma Life Support guidelines
  • ? Rate
  • ? End point 3

Aggressive fluid resuscitation before control of
bleeding. ?May disrupt thrombus formation,
increase bleeding, and decrease survival
4,5 Restricted fluid resuscitation ?negative
effect on tissue perfusion in shocked patients
who respond to fluid with stabilization of their
vital signs
4
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5
2. Material and methods
  • Retrospective analysis
  • Inclusion
  • Adult (age lt16 years)
  • Blunt trauma victims SBP 90 mmHg
  • Standard trauma resuscitation protocols
  • Exclusion
  • No prehospial intravenous fluid
  • Not dead on arrival
  • Referred from other hospital

6
2. Material and methods
  • Rapid bolus infusion of Ringers lactate
  • Data Collected
  • Total fluid volume and
  • Time of initial resuscitation until surgical
    intervention or transfer to the intensive care
    unit (ICU)
  • The clinical outcome, Injury Severity Score
    (ISS), Revised Trauma Score (RTS) and predicted
    probability of survival (?TRISS)

7
3. Results
  • May 1999 Oct 2002,
  • 99 patients (66 males, 33 females)

8
3.1. Patient groups
(included radiological transarterial embolization)
(? ICU)
9
3.2. Clinical characteristics
(20.5)
10
3.3. Hemodynamic response to initial fluid
resuscitation
  • OA On Admission
  • ER End of Resuscitation

11
3.4. Fluid resuscitation
  • the mortality rate can be reduced in such
    patients if the time between initial
    resuscitation and surgical intervention was
    decreased.
  • Patients requiring fluid infusion at more than 60
    mL/min were all hemodynamically unstable and
    required immediate surgical intervention.
  • Limitation to this study
  • Rate of fluid administration was not always
    consistent throughout the resuscitation (patients
    in Group A and B)

12
3.5. Receiver operating characteristic curves
  • The rate of infusion was the best predictor of
    whether uncontrolled hemorrhage requiring urgent
    surgical intervention

45mL/min
0.95 (98CI, 0.920.99)
0.77
  • The cutoff value for the rate of infusion fluid
    (the value closest to the upper left corner of
    the ROC plot) was 45 mL/min (sensitivity, 79.5
    specificity, 91.7).

0.23
0.31
13
4. Discussion
  • ? Rate

14
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15
4. Discussion
  • ? Rate
  • ? End point 3

16
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17
4. Discussion
  • ? Rate
  • ? End point 3
  • KMUH ?????????nonresponders????surgical
    intervention?
  • ??/???????????
  • ?????case?

18
Thank You for Your Attention!
  • Intern Dr. ??? 8901150

19
Notes
  • Shock shock is the clinical syndrome that
    results from inadequate tissue perfusion. Usually
    accompanied by hypotension.

20
Notes
  • Rapid responders, transient responders, or
    minimal or nonresponders
  • Rapid responders ? ? mild hypovolemia, blood
    loss, lt 20. (Class I)
  • Transient responders ? ? Moderate hypovolemia,
    blood loss, between 2040. (Class II III)
  • Non responders ? ? Severe hypovolemia, blood
    loss, gt 40, Class IV

21
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22
Notes
  • Injury Severity Score (ICS)
  • Revised Trauma Score (RTS)
  • Trauma Score-Injury Severity Score (TRISS) ??
    predicted survival rate
  • Receiver operating characteristic (ROC) curves
  • 1-way analysis of variance,
  • Tukey test, or
  • ?2 and Fisher exact tests.

23
The Injury Severity Score (ISS) is an anatomical
scoring system that provides an overall score for
patients with multiple injuries. Each injury is
assigned an Abbreviated Injury Scale (AIS) score
and is allocated to one of six body regions
(Head, Face, Chest, Abdomen, Extremities
(including Pelvis), External). Only the highest
AIS score in each body region is used. The 3 most
severely injured body regions have their score
squared and added together to produce the ISS
score. An example of the ISS calculation is
shown below
Region Injury Description AIS Square Top Three
Head Neck Cerebral Contusion 3 9
Face No Injury 0  
Chest Flail Chest 4 16
Abdomen Minor Contusion of Liver Complex Rupture Spleen 2 5   25
Extremity Fractured femur 3  
External No Injury 0  
Injury Severity Score   Injury Severity Score   Injury Severity Score   50
The ISS score takes values from 0 to 75. If an
injury is assigned an AIS of 6 (unsurvivable
injury), the ISS score is automatically assigned
to 75. The ISS score is virtually the only
anatomical scoring system in use and correlates
slinearly with mortality, morbidity, hospital
stay and other measures of severity.
24
Abbreviated Injury Scale The Abbreviated Injury
Scale (AIS) is an anatomical scoring system first
introduced in 1969. Since this time it has been
revised and updated against survival so that it
now provides a reasonably accurrate was of
ranking the severity of injury. The latest
incarnation of the AIS score is the 1990
revision. The AIS is monitored by a scaling
committee of the Association for the Advancement
of Automotive Medicine. Injuries are ranked on a
scale of 1 to 6, with 1 being minor, 5 severe and
6 an unsurvivable injury. This represents the
'threat to life' associated with an injury and is
not meant to represent a comprehensive measure of
severity. The AIS is not an injury scale, in that
the difference between AIS1 and AIS2 is not the
same as that between AIS4 and AIS5. There are
many similarities between the AIS scale and the
Organ Injury Scales of the American Association
for the Surgery of Trauma.
AIS Score Injury
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Unsurvivable

25
Revised Trauma Score The Revised Trauma Score is
a physiological scoring system, with high
inter-rater reliability and demonstrated
accurracy in predictng death. It is scored from
the first set of data obtained on the patient,
and consists of Glasgow Coma Scale, Systolic
Blood Pressure and Respiratory Rate.
Glasgow Coma Scale (GCS) Systolic Blood Pressure (SBP) Respiratory Rate (RR) Coded Value
13-15 gt89 10-29 4
9-12 76-89 gt29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
  RTS 0.9368 GCS 0.7326 SBP 0.2908 RR
Values for the RTS are in the range 0 to 7.8408.
The RTS is heavily weighted towards the Glasgow
Coma Scale to compensate for major head injury
without multisystem injury or major physiological
changes. A threshold of RTS lt 4 has been proposed
to identify those patients who should be treated
in a trauma centre, although this value may be
somewhat low.
26
Trauma Score - Injury Severity Score TRISS
TRISS determines the probability of survival
(Ps) of a patient from the ISS and RTS using the
following formulae                           
                                   Where 'b' is
calculated from                              
                                                  
                                                  
            
27
4. Discussion
  • Important find the source of blood loss and stop
    it
  • rapid responders, transient responders, or
    minimal or nonresponders
  • Responders ? observed to identify those patients
    with ongoing bleeding requiring surgical control
  • Nonresponders ? immediate surgical intervention

28
4. Discussion
  • Aggressive fluid resuscitation before control of
    bleeding.
  • May disrupt thrombus formation, increase
    bleeding, and decrease survival
  • Restricted fluid resuscitation
  • negative effect on tissue perfusion in shocked
    patients who respond to fluid with stabilization
    of their vital signs

29
4. Discussion
  • Patients requiring fluid infusion at more than 60
    mL/min (nonresponders) were all hemodynamically
    unstable and required immediate surgical
    intervention.
  • The rate of infusion was the best predictor of
    whether uncontrolled hemorrhage requiring urgent
    surgical intervention
  • The cutoff value for the rate of infusion fluid
    (the value closest to the upper left corner of
    the ROC plot) was 45 mL/min (sensitivity, 79.5
    specificity, 91.7).
  • It would take 20 to 45 minutes for an adult
    patient to receive the standard 1-2 L crystalloid
    infusion recommended by the Advanced Trauma Life
    Support guidelines at this rate.

30
4. Discussion
  • Increasing the fluid administration rate did not
    produce hemodynamic stability.
  • The rate of infusion was the best predictor of
    whether uncontrolled hemorrhage would occur

31
4. Discussion
  • Limitation to this study
  • Rate of fluid administration was not always
    consistent throughout the resuscitation (patients
    in Group A and B)

32
4. Discussion
  • A rapid infusion rate does not restore blood
    pressure if the concomitant bleeding is occurring
    at a greater rate 10
  • The mortality rate can be reduced in Group C
    patients if the time between initial
    resuscitation and surgical intervention was
    decreased.
  • Initial imaging assessment
  • The rate of infusion required

33
2. Material and methods
  • P lt .05,
  • as determined by
  • 1-way analysis of variance,
  • Tukey test, or
  • ?2 and Fisher exact tests.

34
3.4. Fluid resuscitation
35
3.5. Receiver operating characteristic curves
45mL/min (sen. 79.5 spc. 91.7)
0.95 (98CI, 0.920.99)
0.77
0.23
0.31
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