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Massive Bleeding

A. Prof. Dr. Dietmar Fries

Clinical Division for

General and Surgical Critical Care MedicineMedical University Innsbruck, Austria

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conflict of interest:Astra Zeneca, Baxter, Braun,

Biotest, CSL Behring, Delta Select,

Dade Behring, Fresenius, Glaxo,

Haemoscope, Hemogem, Lilly, LFB,

Mitsubishi Pharma, NovoNordisk,

Pentapharm

international collaboration:Tel HashomerMedical University of TelAviv, Israel

US Army, Fort Sam Houston, Texas, USA

Coalition Warefare Program - US Army

Dept. of Bioengineering, Univ. of San Diego, USA

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Definition: Massive Bleeding

Definitions include:

;Loss of 50% circulating volume in 3 hours;Loss of greater than 150 ml min-1

;Loss of whole blood volume within 24 hours

NHS 2006

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blood loss

dilutiontransfusion

hypovolemiacoagulopathy

Morbidity/Mortality

Vicious Circle

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Fluid therapy in haemorrhagicshock?

Massive Transfusion Protocols

Target Controlled Bleeding

Management

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Evidenced Based Literature (Cochrane Library)

Is the normalisation of blood pressure in bleeding traumapatients harmful ? Roberts I Lancet 2001 ...no evidence for effectivness ... ...resuscitation practice can at best be regarded as

experimental

Colloid solutions for fluid resuscitation. Bunn F 2003... no evidence that one colloid is more effective or safethan any other ...

Timing and volume of fluid administration for patientswith bleeding following trauma. Kwan I 2003...uncertainity about the best fluid administration strategy

in bleeding trauma patients ...

Hypertonic versus isotonic crystalloid fluid resuscitationin critically ill patients. Bunn F 2002...not enough data to be able to say whether hypertoniccrystalloid is better than isotonic crystalloid ...

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Immediate versus dalayed fluid resuscitation forhypotensive patients with penetrating torso injuriesBickell W.H. et al. NEJM 1994; 331: 1105-9

n = 598 patients

age: 31a 11 systolic blood pressure: 90 mmHg penetrating chest trauma

immediate fluid resuscitation (n= 309): 62% survivors

delayed fluid resuscitation (n=289): 70% survivors

p=0.04 !!!

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Statistics: Fisher Exact Test

Survivor Non Survivor

delayed fluid

replacement

193 116

203 86

p=0.04

immediatefluid

replacement1 patient

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Statistik: Fisher Exact Test

Survivor Non Survivor

delayed fluid

replacement

193 116

202 87

p=0.057

immediatefluid

replacement

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Immediate versus dalayed fluid resuscitation for hypotensivepatients with penetrating torso injuries

Bickell W.H. et al. NEJM 1994; 331: 1105-9

but : ...

22 patients within the delayed group received fluid

70 patients died before surgery (41/29)

immediate fluid resuscitation

(n= 309): 62% survivors

delayed fluid resuscitation(n=289): 70% survivors p=0.04

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Patients (n=110) with haemorrhagic shock were randomized:

1. target SBP > 100 mm Hg

2. target SBP of 70 mm Hg

Fluid therapy was titrated to this endpoint

Hypotensive resuscitation during activeHaemorrhage: impact on in hospital mortality

Dutton RP: J Trauma (2002) 6:1141

SBP > 100 mmHg SBP = 70 mmHg

active bleeding 2,97 min 2,57 min

(n.s.)

death 4 4 (n.s.)

predicted survival 94% 90% (n.s.)

actual survival 92,7% 92,7% (n.s.)

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800 1.000 mL

50 400 mL

500 5.000 mL

300 2.000 mL

100 1.000 mL

Hypovolemia

blood volumeCO and DO2

macrocirculation

vasoconstriction

perfusion

microcirculation

ischemia MOF gut, kidney,

Endotoxemia

septicshock

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Protein C activation

due to shock,hypoperfusion

increased pT and apTT due

to increased BE

Increased BE: high

thrombomodulin and

decreased protein C

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Compartment Glucose 5% Crystalloid Colloid

intravascular

interstitial

intracellular

Fluid Compartments and Resuscitation

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Fluid therapy in haemorrhagicshock? Yes!

Massive Transfusion Protocols

Target Controlled Bleeding

Management

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American Society of

Anesthesiologists:

Newsletter July 2009

1:1:1 ratio needs more studies there is significant survivor bias

use of POC monitoring avoids unnecessary

transfusion 1:1:1 ignores the risk of allogenic transfusion

known to be dose dependent

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Coagulation management with FFP and clotting factor

concentrates in severe traumatized patient:CT scan at admission to trauma centre

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15 FFP 10 g Fibrinogen

6 mm 3 mm 27 mm

48 mm 27 mm 61 mm

232 mg/dL 60 mg/dL 285 mg/dL

FibTEM MCF:

exTEM MCF:

Fibrinogen:

12 RBC1 TK

Coagulation management with FFP and clotting factorconcentrates in severe traumatized patient

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Each unit of FFP was independently

associated with a 2.1% higher risk of

MOF and a 2.5% higher risk of ARDS.Treatment - FFP

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sequence of critical of clotting factorconcentrations :

1. Fibrinogen

2. Prothrombin

3. Factor V

4. Factor VII

5. Platelets

Hiippala ST Anesth Analg 1995

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recommendation 28:

we recommend treatment with FI if signif icant bleeding is

accompanied by TEG signs of functional fibrinogen deficit or a

plasma FI level of less than 1.5 2.0 g/l (Grade 1C). We suggestan initial f ibrinogen concentrate dose of 3-4g or50mg/kg.

Repeated doses may be guided by TEG monitoring and

laboratory assessment (Grade 2C).

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Coagulation Management in traumatized and massiv

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g gbleeding patients

Task Force for perioperative Coagulation (AGPG) of theAustrian Society for Anaesthesia, Critical Care Medicine andEmergency Medicine (GARI)1. anaemie: 8 9 (10) g/dL.

2. avoid hypothermia, warm infusion solutions, active warming if possible

3. acidosis: buffer therapy, if coagulation therapy is indicated

2. hyperfibrinolysis: consider the use of tranexamic acid in all kind of

massive transfusion

3. platelets: > 50.000 100.000 x103l

4. FFP: patients with severe trauma and coagulopathy will not recover

from FFP alone; targeted administration of clotting factors is favorable.

5. fibrinogen: > 1,5 g/dL 2,0 g/dL

6. rFVIIa: if surgery, interventional radiology, packing, etc. fails and only

after appropriate coagulation therapy.

7. local hemostyptic wound deressings: QuickClot, Hemcon, CombatGauze, etc. are much more effective than standard gauze dressing

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