Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

Abstract

The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.

In silico model of the dilutional effects of conventional component therapy versus whole blood in the management of massively bleeding adult trauma patients

“…Thus, the current approach to resuscitating trauma patients involves early intervention with blood products that can help achieve these ends. 13 However, not all blood products contain the same quantity of non-oxygen-carrying, nonhemostatic fluids that keep them anticoagulated and/or extend their shelf life. In a whole blood (WB) collection, 500 mL of WB is added to 70 mL of citrate-phosphate-dextrose (CPD) solution.…”

“…17 Briefly, the model comprised four interconnected modules: a hemostatic module, resuscitation module, body fluid compartment module, and dilutional coagulopathy module. The model was divided into five phases: an initial injury phase (minutes 1-10), a prehospital resuscitation phase (minutes [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30], an emergency department (ED) resuscitation phase (minutes 31-60), an operating room (OR) resuscitation phase (minutes 61-160), and a recovery phase (minutes 161-240). The duration of the initial injury phase and prehospital resuscitation phase were based on local experience and data from a randomized trial conducted at a Level 1 US civilian trauma center.…”

Blood components – so much more than clots and oxygen delivery!

“…The usual indications for plasma transfusion are bleeding diathesis caused by coagulation factor deficiency(ies) (when no factor‐specific concentrate is available) and massive haemorrhage as a part of balanced resuscitation with blood components. There is emerging evidence that plasma is superior to crystalloids and colloids as an early resuscitation fluid in massive haemorrhage both through its haemostatic as well as its endothelial protective and repairing properties .…”

Hypovolemic Shock

“…Crystalloids and colloids have been associated with inflammation, hemodilution, edema, abdominal compartment syndrome, renal failure and coagulation disorder. 14,[28][29][30][31] Fluid replacement can be monitored by dynamic methods with advantages over static variables and vital signs. 23 In cases of severe bleeding and massive blood replacement, some criteria observed in recent years should be taken into account: loss of blood viscosity, coagulation changes due to hemodilution and fibrinolysis.…”