FLUID RESUSCITATION AND

TRANSFUSION THERAPY IN TRAUMA

Reno Rudiman
Department of Surgery
Medical School Universitas Padjadjaran/
Dr Hasan Sadikin Hospital, Bandung
PRINCIPLES AND PROTOCOLS FOR
INTRAVENOUS FLUID THERAPY

• 1. Fluid resuscitation

• 2. Routine maintenance

• 3. Replacement

• 4. Redistribution
1. FLUID RESUSCITATION
• Loss of intravascular volume
• Bleeding
• Plasma loss
• Excessive Fluid and Electrolyte loss
• External: GI severe disease
• Internal: Sepsis

National Clinical Guideline Centre (UK). Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital
[Internet]. London: Royal College of Physicians (UK); 2013 Dec. (NICE Clinical Guidelines, No. 174.)
2. ROUTINE MAINTENANCE

• IV fluids are sometimes needed for patients who simply cannot

meet their normal fluid or electrolyte needs by oral or enteral routes

• Even when prescribing IV fluids for more complex cases, there is

still a need to meet the patient’s routine maintenance requirements,
adjusting the maintenance prescription to account for the more
complex fluid or electrolyte problems.

National Clinical Guideline Centre (UK). Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital
[Internet]. London: Royal College of Physicians (UK); 2013 Dec. (NICE Clinical Guidelines, No. 174.)
3. REPLACEMENT

• In some patients, IV fluids to treat losses from intravascular and or

other fluid compartments, are not needed urgently for resuscitation,
but are still required to correct existing water
and/or electrolyte deficits or ongoing external losses

• These losses are usually from the GI or urinary tract, although high
insensible losses occur with fever, and burns patients can lose high
volumes of what is effectively plasma

National Clinical Guideline Centre (UK). Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital
[Internet]. London: Royal College of Physicians (UK); 2013 Dec. (NICE Clinical Guidelines, No. 174.)
4. REDISTRIBUTION
• In addition to external fluid and electrolyte losses, some hospital
patients have marked internal fluid distribution changes or abnormal
fluid handling

• Seen particularly in those who are septic, otherwise critically ill, post-
major surgery or those with major cardiac, liver or renal co-morbidity

• Many of these patients develop edema from sodium and water

excess and some sequester fluids in the GI tract or
thoracic/peritoneal cavities

National Clinical Guideline Centre (UK). Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital
[Internet]. London: Royal College of Physicians (UK); 2013 Dec. (NICE Clinical Guidelines, No. 174.)
PRINCIPLES OF FLUID THERAPY

• The physiology of fluid balance in health;

• Pathophysiological effects on fluid balance;

• Clinical approaches to assessing IV fluid needs;

• The properties of available IV fluids

THE PHYSIOLOGY OF FLUID BALANCE IN HEALTH
NORMAL ANATOMY & PHYSIOLOGY
FLUID BALANCE
Intake (ml) Output (ml)
Water from beverages 1200 Urine 1500

Water from solid food 1000 Insensible losses 500 – 1000

from skin and lungs

Metabolic water from 300 Faeces 100

oxidation
AVERAGE DAILY INTAKE

Water 25–35 ml/kg/day

Sodium Approx. 1 mmol/kg/day
Potassium Approx. 1 mmol/kg/day
INITIAL ASSESSMENT
Indicators that a patient may need urgent fluid resuscitation include:
• Systolic blood pressure is less than 100 mmHg
• Heart rate is more than 90 beats per minute
• Capillary refill time is more than 2 seconds or peripheries are cold
to touch
• Respiratory rate is more than 20 breaths per minute
• National Early Warning Score (NEWS) is 5 or more
• Passive leg raising suggests fluid responsiveness
NATIONAL EARLY WARNING SCORE

R.J.M Morgan, F Williams, and Wright MM. An early warning scoring system
for detecting developing critical illness. Clinical Intesive Care, 8:100, 1997.
RESUSCITATION

• If patients need IV fluid resuscitation, use crystalloids that contain

sodium in the range 130–154 mmol/l, with a bolus of 500 ml over
less than 15 minutes

• Do not use tetrastarch for fluid resuscitation

• Consider human albumin solution 4–5% for fluid resuscitation only

in patients with severe sepsis.
ROUTINE MAINTENANCE
• If patients need IV fluids for routine maintenance alone, restrict the
initial prescription to:
• 25–30 ml/kg/day of water and
• approximately 1 mmol/kg/day of potassium, sodium and
chloride and
• approximately 50–100 g/day of glucose to limit starvation
ketosis

• For patients who are obese, adjust the IV fluid prescription to their
ideal body weight.
REPLACEMENT AND REDISTRIBUTION
• Adjust the IV prescription (add to or subtract from maintenance needs) to
account for existing fluid and/or electrolyte deficits or excesses, ongoing losses
or abnormal distribution

• Seek expert help if patients have a complex fluid and/or electrolyte redistribution
issue or imbalance, or significant comorbidity, for example:
• gross oedema
• severe sepsis
• hyponatraemia or hypernatraemia
• renal, liver and/or cardiac impairment
• post-operative fluid retention and redistribution
• malnourished and refeeding issues
 FLUID RESUSCITATION ALGORITHM

‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)
TRANSFUSION IN TRAUMA
• The foremost reason of death among 1-40 years old is traumatic
injury, with an estimate of five million deaths per year globally
among which an estimated 10-20% of deaths are preventable

• Uncontrolled haemorrhage within 6 h of injury is one of the prime

causes of avoidable death, which led many trauma specialists to
find ways to reduce early mortality due to severe injuries.
TRANSFUSION IN TRAUMA
• Patients who present to the emergency in hypovolemic shock and
coagulopathy are more likely to receive massive blood
transfusions, which increase mortality

• Morbidity and mortality are four times higher in patients who

develop trauma-induced coagulopathy

• Early recognition of these patients remains a crucial goal of

resuscitation to increase chances of survival by early aggressive
treatment
TRAUMA INDUCED COAGULOPATHY

• Trauma-induced coagulopathy is a condition in which various

elements like acidosis, hypothermia, haemodilution and
consumption of clotting factors from transfusion of crystalloids and
PRBCs play a crucial role

• It is a significant predictor of blood utilisation and trauma-related

mortality and is iatrogenic
TRAUMA INDUCED COAGULOPATHY
MASSIVE TRANSFUSION
• Recent studies have suggested that only 25% of trauma patients
require a blood transfusion, and only 2-3% of them receive a
massive transfusion (MT)

• A patient transfused with ten or more packed red blood cells

(PRBCs) within first 24 h is said to have received a MT.

• These patients are at high risk of early haemorrhagic death with a

mortality rate of 40-70%.

Como JJ, Dutton RP, Scalea TM, Edelman BB, Hess JR. Blood transfusion rates in the care of acute trauma.
Transfusion. 2004;44:809–13
 FIBRINOGENS
• Thousand milligrams (mg) of fibrinogen are present in a unit of
whole blood, so the loss of one unit of whole blood, dissipates 1000
mg of fibrinogen.

• This loss is usually, restored with transfusion of one unit of both

PRBC and fresh frozen plasma (FFP), where 1 unit of FFP contains
only 500 mg of fibrinogen in it.

• In later stages, it is necessary to add more fibrinogen to restore the

deficit.

Holcomb JB. Optimal use of blood products in severely injured trauma patients. Hematology Am Soc Hematol Educ
Program 2010. 2010:465–9
FIBRINOGENS
• One unit of cryoprecipitate contains 0.25 g of fibrinogen, and this
ratio can be obtained by transfusing cryoprecipitate: PRBC in a 1:1
ratio.

• In clinical practice in the ED, for every ten units of PRBCs

transfused, transfuse ten units of cryoprecipitates.

• Shaz et al., has shown transfusion of cryoprecipitate and PRBCs in

the ratio of 1:1 has higher 24-hour, and 30-day survival after MT in
trauma

Shaz BH, Dente CJ, Nicholas J, MacLeod JB, Young AN, Easley K, et al. Increased number of coagulation products in
relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion. 2010;50:493 –500
PLATELETS
• Perkins et al. focused on platelet to PRBCs ratios in military trauma,
and observed improved 24-h and 30-days survival rates in a high-
ratio group which received approximately 1:1 platelets to PRBCs in
comparison to other groups

• The current resuscitation approach is to use 1:1:1 FFP: PRBCs:

Platelets in resuscitation for all casualties who are expected to
receive an MT

Perkins JG, Cap AP, Spinella PC, Blackbourne LH, Grathwohl KW, Repine TB, et al. An evaluation of the impact of
apheresis platelets used in the setting of massively transfused trauma patients. J Trauma. 2009;66:S77 –84.
WARM FRESH WHOLE BLOOD
• Warm fresh whole blood (WFWB) transfusion of 500 ml carries a
decent haematocrit level and no storage deficits.

• WFWB is healthier and more beneficial to patients as they contain

an optimum amount of clotting factors; platelets and fibrinogen.

• A 1:1:1 ratio of plasma, PRBCs and platelets component therapy

does not contain equivalent amounts of clotting factors, platelets or
fibrinogen as WFWB does

Armand R, Hess JR. Treating coagulopathy in trauma patients. Transfus Med Rev. 2003;17:223 –31
DAMAGE CONTROL RESUSCITATION
• Early definitive haemorrhage control
• Early and increased use of 1:1:1 FFP, PRBC and platelets, and
minimising crystalloids
• Avoiding hypothermia, acidosis and coagulopathy
• Hypotensive resuscitation strategies
• Use of other products like Ca2+, rFVII, tranexamic acid, and tris-
hydroxymethyl aminomethane should be deliberated.

Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, et al. Damage control
resuscitation: Directly addressing the early coagulopathy of trauma. J Trauma. 2007;62:307 –10.
SUMMARY
• In a trauma patient with life-threatening injuries, early identification
of coagulopathy and treating it in 1:1:1 ratio, with thawed plasma,
PRBCs, and platelets, limited use of crystalloids and rapid
haemorrhage control will improve their survival.

• These principles of DCR should only be utilised in resuscitation of

patients with haemorrhagic shock and life-threatening injuries, and
one should be cautious not to overuse DCR principles