Recommendations for the resuscitation of patients who have sustained blunt or penetrating trauma continue to evolve, especially for those patients who present with, or who develop, coagulopathy (defined as requiring more than 10 U of packed red blood cells [pRBCs] over 24 hours). During the Vietnam War, Miller et al.1 noted that those patients who present with hemorrhagic shock are at high risk for developing coagulopathy, partly because of the resuscitation-related dilution of coagulation factors, including dilutional thrombocytopenia. Two decades later, Bickell et al.2 subsequently conducted a somewhat controversial prospective study demonstrating that the resuscitation of trauma victims with crystalloid fluids before hospital arrival was associated with increased morbidity and mortality. The study was controversial because it was one of the early studies of prehospital patients who were randomly assigned to the “experimental” group or the conventional treatment group without their consent but with IRB approval of the study.3 Without societal willingness to approve such studies, the care of patients in extremis who are unable to consent (as most of us understand consent) to enrollment in a prospective randomized study would have been significantly delayed. As it was, and as it is with most such results, the time (the hysteresis) before the results of the study were incorporated into clinical practice was more than 10 years.
During the early days of Operation Enduring Freedom and Operation Iraqi Freedom, forward surgical teams and personnel at combat support hospitals cared for a number of soldiers who developed abdominal compartment syndrome, which arises secondary to a number of factors, one of which is the amount of crystalloid administered. On the basis of such observations and studies such as Bickell et al.,2 the current recommendations of the U.S. Military’s Joint Theater Trauma System advise clinicians to limit the amount of crystalloid used to resuscitate wounded soldiers.4
Other studies conducted during the past decade, including TRICC,5 SAFE,6 and FOCUS,7 have affected practice perhaps more quickly, having done so because they supported a gestalt that less may be more when managing critically ill patients. During this time period, the transfusion threshold, the hemoglobin level at which patients are administered RBCs, has gone from 10 g/dL to 8 g/dL and is now hovering closer to 7 g/dL, even for patients who are at higher risk of having coronary artery disease.7 The SAFE study demonstrated that resuscitation with a colloid (albumin) of patients once they were admitted to the intensive care unit (ICU) did not affect outcome.6 The 6S study (Scandinavian Starch for Severe Sepsis/Septic Shock Trial)8 demonstrated that patients with severe sepsis resuscitated with hydroxyethyl starch (130/0.42) had an increased risk of death at day 90 and were more likely to have required renal replacement therapy, as compared with those receiving Ringer’s acetate solution. The results of CHEST (Crystalloid versus Hydroxyethyl Starch Trial),9 which randomized several thousand patients who were in ICUs to receive either crystalloid or hydroxyethyl starch, were released in October of this year, and though the investigators did not find an increased incidence of death at 90 days, they did confirm the results of the 6S study in that more patients who received hydroxyethyl starch required renal replacement therapy.
However, if these studies show that albumin is no better than crystalloid and that hydroxyethyl starch may be worse than crystalloid, albeit when infused in a slightly different population, that is, patients in ICUs and not patients requiring resuscitation in a field environment, emergency department, or operating room, perhaps crystalloid is not the culprit some thought it to be; instead, perhaps it is the “volume” of fluid administered to bleeding patients that results in coagulopathy. I hasten to point out that the previously cited studies were conducted in the prehospital environment or in the ICU or during the perioperative period not specifically limited to the operating room in actively bleeding patients. In the latter setting, a slightly different resuscitation strategy is the norm.10 However, when the results of all of these studies are taken together, many contend that the net results support the concept of damage-control surgery or resuscitation.11 The most important goal of resuscitation is to stop the bleeding from whatever source to avoid the need to administer large volumes of any fluid. When fluid must be administered, one should replace what was lost (i.e., ideally, with whole blood if many trauma surgeons had their preference)12 or as a ratio of pRBCs to fresh frozen plasma of 1:113 or of pRBCs to fresh frozen plasma to platelets of 1:1:1.4 The latter observations have been called into question because of the survival basis inherent in some of the observational studies that support a fixed ratio of blood products when resuscitating coagulopathic patients.
The reality, though, is that, even if the bleeding is stopped immediately and providers use whichever RBC product in which they fervently believe, with a hemoglobin target of only 7 g/dL to 9 g/dL, most anesthesiologists will administer IV fluid. The goal is to maintain preload and left ventricular output; with a lower hemoglobin concentration and lower oxygen content, oxygen delivery is very dependent on cardiac output. A recent multicenter survey demonstrated that physicians in the ICU continue to administer large volumes of fluid, the choice of which varies by country,14 and I suspect that the same is true in most operating rooms. But are these physiologic goals, once the foundation of resuscitation in shock, still valid?
In this issue of Anesthesia & Analgesia, Tobin and Varon15 review the basis for damage-control resuscitation and for the use of blood products in managing the coagulopathy associated with trauma. They provide an excellent review of the survival bias inherent in several of these observational studies, as mentioned earlier. Of more scientific validity, as they describe, is that, at least in 1 study, the use of tranexamic acid has been associated with an improvement in outcome. The use of recombinant Factor VIIa is more controversial; many proponents interpret the results of disparate studies to their advantage. The overview provided by Tobin and Varon15 is more compelling in putting this debate in perspective. Of more importance, perhaps, they review the most recent development in resuscitation, the concept of “hypotensive” resuscitation with a goal of a systolic blood pressure of 90 mm Hg in patients with polytrauma, or 100 mm Hg in patients with head injury, until the bleeding can be controlled. Vasopressin is reviewed as a vasoconstrictor used to maintain systemic blood pressure at a goal considerably less than was once acceptable. Maintenance of systemic blood pressure by increasing systemic vascular resistance in contradistinction to the maintenance of pressure by increasing cardiac output (and parenthetically oxygen delivery) seems counterintuitive to what we were once taught and understand about cardiovascular and cellular physiology, but Tobin and Varon cite interesting animal data and case reports and observational studies of patients.
Time will tell whether they are clairvoyant, but there can be no doubt that the resuscitation of patients who have sustained polytrauma has changed dramatically from what it once was, a wide-open IV line delivering liter on liter of crystalloid and non–heme-containing colloid. We can’t go home again, nor would most of us desire to do so. Some readers will be early adapters, or at least try these new approaches cautiously; some will be resistant, and a few will never change. Irrespective of what we as individuals do, on the basis of experience gained by military physicians in recent conflicts and by physicians in civilian trauma centers, our resuscitation of patients who have sustained major trauma will continue to evolve and improve through research, observation, and experience. As perioperative physicians, it behooves us to be cognizant of these developments.
Name: Michael J. Murray, MD, PhD.
Contribution: This author wrote the manuscript.
Attestation: Michael J. Murray attests that the work is original and all his own writing.
This manuscript was handled by: Jerrold H. Levy, MD, FAHA.
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