Perioperative Hemodynamic Monitoring and GDT Concepts in Trauma

Perioperative Goal-Directed
Optimization Concepts
Dita Aditianingsih MD
Thursday, November 6, 14
Topics
• Perioperative Hemodynamic and Shock

Managements in :
• High-Risk Surgery
• Hypovolemic-Hemorrhagic Shock in
Trauma
High-Risk Surgery
Introduction Case
Male 83 y.o with Bladder
carcinoma, AKI – R, CAP
Elective Ileal conduit Surgery
with ASA 3
Post surgery in the ICU :

- Extubated after 24 hrs of
admission
- Re-Intubated on day 3
Suffered from:
- AKI – F , IHD
- VAP
Died in ICU 2 weeks later
Female, 78 y.o, HHD, CHF gr 3-4,
septic shock ec diverticular
perforation , pneumoperitoneum.
Lactate 4, PCT 100
Intubated, CVC insertion
Fluid resuscitation with ivc usg
guided
Vasopressor, inotrope, broad
spectrum empirical antibiotics
Emergency Surgery with ASA 4
Post surgery :
Septic, AKI – F, VAP
Died in ICU 4 days later
Incidence
• Trauma, major surgery and severe sepsis are commonly associated
with life-threatening hypovolemia and reductions in myocardial
contractility and vascular tone.
• Account for the majority of peri-operative morbidity and mortality
(<15% of in patient procedures but >80% mortality)
• Have a poor outcome due to their inability to meet the oxygen
transport-demands imposed by the nature of the surgical response
during the peri-operative period.
• Optimal fluid administration combined with vasoactives aim to
prevent hypovolemia and end-organ hypoperfusion, but also
preventing edema formation from excessive fluid loading
Jhanji et al Anaesthesia 2008; 63(7): 695-701
Mortality following non-cardiac surgery in an NHS Trust
Mortality following non-cardiac surgery in an NHS Trust
Less than 1/3 of high-risk

patients are admitted to
critical care
Risk prediction for common surgical procedures
performed in the UK
Aylin et al. BMJ; 2007
Unruptured
Colo-rectal Ruptured AAA CABG
AAA
Database size 144,370 31,705 12,781 152,523
Overall 10,424 3,246 3,247

5,987 (46.8%)
mortality (7.2%) (10.2%) (2.1%)
Effect of
Urgency 3.46 2.76 1.38 1.54
(odds ratio)
Why are outcomes

so much better
for cardiac surgical patients?
performed in the UK
Unruptured
AAA
Database size 144,370 31,705 12,781 152,523
Overall 10,424 3,246 3,247

5,987 (46.8%)
mortality (7.2%) (10.2%) (2.1%)
Effect of
Urgency 3.46 2.76 1.38 1.54
(odds ratio)
Why are outcomes

so much better
for cardiac surgical patients?
performed in the UK
Unruptured
AAA
Database size 144,370 31,705 12,781 152,523
Overall 10,424 3,246 3,247

5,987 (46.8%)
mortality (7.2%) (10.2%) (2.1%)
Effect of
Urgency 3.46 2.76 1.38 1.54
(odds ratio)
• Younger / Fitter /
Elective
Why are outcomes • Efficient care pathway for
so much better single disease group
• Post-operative intensive
for cardiac surgical patients? care is standard
Fleisher LA, Beckman JA, Brown KA, et al. ACC/
AHA 2007 guidelines on perioperative

cardiovascular evaluation and care for
noncardiacsurgery. Circulation 2007; 116: 1971–96.
• POSSUM stands for Portsmouth-Physiological
and Operative Severity Score for the
enUmeration of Mortality and Morbidity.
• It was developed by Copeland et al in 1991
• Physiological parameters
• Operative parameters
NYHA, METS,
CPET
P-POSSUM
score,
ASA
BNP, CRP,
creatine,
GFR
Anaerobic
treshold <11 /kg/
min
NYHA, METS,
CPET
P-POSSUM
score,
ASA
BNP, CRP,
creatine,
GFR
Anaerobic
treshold <11 /kg/
min
NYHA, METS,
CPET
P-POSSUM
score,
ASA
BNP, CRP,
creatine,
GFR
Anaerobic
treshold <11 /kg/
min
Clinical criteria for high-risk
surgical patients
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal directed therapy after major surgery reduces complications and
duration of hospital stay. A randomised controlled trial. Crit Care 2005; 9: R687–93
Relationship between perioperative fluid volume
and post-‐operative morbidity
Morbidity
Bundgaard-‐Nielsen M, et al. ‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy—a critical assessment of the evidence. Acta
Anaesthesiol Scand 2009
Morbidity
Morbidity
Procedure
Comorbidities
Preop hydration
Bowel preparation
Anaesthesia/neuroaxial blockade
Morbidity
Procedure
Comorbidities
Preop hydration
Restrictive Bowel preparation
Morbidity
Procedure
Comorbidities
Preop hydration
Hypovolemia
Morbidity
Procedure
Comorbidities
Preop hydration
Bowel ischemia
Hypovolemia
Morbidity
Procedure
Comorbidities
Preop hydration
Bowel ischemia
é risk of:
Organ hypoperfusion
SIRS
Sepsis
MOF
Hypovolemia
Morbidity
Procedure
Comorbidities
Preop hydration
Restrictive Bowel preparation Liberal
Bowel ischemia
é risk of:
Organ hypoperfusion
SIRS
Sepsis
MOF
Hypovolemia
Morbidity
Procedure
Comorbidities
Preop hydration
Bowel ischemia
é risk of:
Organ hypoperfusion
SIRS
Sepsis
MOF
Hypovolemia Hypervolemia
Morbidity
Procedure
Comorbidities
Preop hydration
Bowel ischemia Bowel edema

é risk of:
Organ hypoperfusion
SIRS
Sepsis
MOF
Morbidity
Procedure
Comorbidities
Preop hydration

é risk of: é crisk of:
Organ hypoperfusion Organ edema
SIRS Ileus
Sepsis PONV
MOF Pulmonary complication
é cardiac demands
Morbidity
Procedure
Comorbidities
Preop hydration

SIRS Ileus
Sepsis PONV
Hypovolemia
Normovolemia Hypervolemia
Morbidity
Procedure
Comorbidities
Preop hydration

SIRS Ileus
Sepsis PONV
Hypovolemia
Morbidity
Procedure
Comorbidities
Preop hydration

Goal-‐directed é crisk of:
é risk of:
Organ hypoperfusion optimalization Organ edema
SIRS Ileus
Sepsis PONV
Hypovolemia
Pathophysiology: Why do patients
develop postoperative complications?
• Tissue injury-induced inflammatory response
• The preexisting disease state
• Imbalance Tissue oxygen delivery DO2 and

consumption VO2
Majority of postoperative complications :

infection, myocardial ischemia, thrombosis,
Multiorgan Dysfunction
Pathophysiology: Why do patients
develop postoperative complications?
• Tissue injury-induced inflammatory response
• The preexisting disease state
• Imbalance Tissue oxygen delivery DO2 and

consumption VO2
Majority of postoperative complications :

infection, myocardial ischemia, thrombosis,
Multiorgan Dysfunction
Tissue oxygen delivery (DO2)
and oxygen consumption (VO2)
• DO2=CO x CaO2
=CO × (1.34 × Hb × SaO2)
• VO2 = CO x (CaO2 - CvO2)
= CO x 1.34 x Hb x (SaO2 - SvO2)
• OER is the ratio of VO2 to DO2, and
organ specific
Basal metabolism :
VO2 of 250–300 mL/minute, i.e. 3.5 mL/kg.
pain, anxiety, sepsis, fever increase VO2
hypothermia, anesthesia, hypothermia decrease VO2
1.34: oxygen-binding capacity of hemoglobin

[Hb]: 8-10 g/dl
SaO2: arterial oxygen saturation >95%
SvO2: mixed venous oxygen saturation >70%
Oxygen Delivery - Oxygen
Consumption Relationship Curve
OXYGEN DELIVERY (DO2)
OXYGEN CONSUMPTION (VO2)
OXYGEN Extraction (O2ER)
NORMAL PHYSIOLOGIC STATE

oxygen
Critical DO2 Values


oxygen
Critical DO2 Values

Shock
oxygen
Critical DO2 Values

High-risk Surgical Patients

Shock
oxygen
Critical DO2 Values


Shock
oxygen
Critical DO2 Values


Shock
oxygen
Critical DO2 Values


Shock
oxygen
Critical DO2 Values


SvO2
Shock
oxygen
Critical DO2 Values


SvO2
Shock
oxygen
lactate
Base deficit
Critical DO2 Values

SUPRANORMAL DO2 ↑ Preload, inotropes

SvO2
Shock
oxygen
lactate
Base deficit
Perioperative Hemodynamic
Instabilities
⬇︎Blood Pressure- ⬇︎Cardiac Output ⬇︎Systemic Vascular Resistance
Mean Arterial Pressure CO SVR
⬇︎Stroke Volume ⬇︎Heart Rate
⬇︎Preload ⬇︎Contractility ⬇︎Afterload
Hypovolemia Cardiac Vasodilatation

Dysfunction
Fluid Shifting Heart disease Anesthetic drugs

Blood Loss Comorbids Sepsis
Positive Pressure Anesthetic drugs Reperfusion Injuries
Ventilation
Fluid, blood tranfusions Inotropes Vasopressors

Ventilator adjustment
Instabilities
⬇︎Blood Pressure-
Mean Arterial Pressure
= ⬇︎Cardiac
CO
Output ⬇︎Systemic Vascular Resistance
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
x ⬇︎Systemic Vascular Resistance
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR
⬇︎Stroke Volume x ⬇︎Heart Rate

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Instabilities
= ⬇︎Cardiac
CO
Output
SVR

Dysfunction

Ventilation

Supranormal Target using The Frank-Starling curve representing
the non-linear relationship between
ventricular preload and ventricular stroke volume
Cardiac Output
Cardiac Output
Cardiac Output
Cardiac Output
Fluid Volume Administration

Cardiac Output

Cardiac Output Dobutamin, Fluid


⬆︎︎Contractility improved




⬇︎Contractility impaired

Perioperative Management
• Respiratory management :
- Early vs delayed intubation
- Early vs delayed extubation
- CPAP
• Cardiovascular management:
- Inotropes and rate control
- Fluid therapy : restrictive vs liberal
- Perioperative Goal-Directed
Haemodynamic therapy
Goal-Directed Therapy (GDT)
• Target specific values for cardiac output, O2

delivery, O2 consumption
• Use fluids and inotropes
• ↓ mortality and morbidity
• ⬆︎O2 delivery (DO2) = ⬆Cardiac output (CO) x
⬆Arterial oxygen content (CaO2)
Shoemaker WC et al. Chest 1988;94:1176-86
Pulmonary arterial pressures, HR.
MAP,CVP, pulmonary capillary WP
Arterial and mixed venous saturation,
pH, blood gas tensions,hemoglobin,
hemoglobin saturation, hematocrit
Cardiac output then was measured by
thermodilution
DO2 measured by calculated CI and
arterial oxygen content (per BSA)
The therapeutic goals

supranormal values :
CO (>4.5 L/min.m)
DO2 (>600 ml/min.m2)
VO2 (>170 ml/min.m2)
thermodilution

CO (>4.5 L/min.m)
thermodilution

CO (>4.5 L/min.m)
The Goal Directed Therapy
includes :
fluid loading , tranfusion and
inotropes, to optimize the
preload, contractility and
afterload of the heart and
maintaining an adequate
coronary perfusion pressure
includes :
includes :
Static : CVP, PAOP
Volumetric : PAC, PICCO,
LidCO
Echocardiographic : Echo,
TEE
Dynamic : SVV, PPV, PLR
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds

RM, Bennett ED: Early goal-directed therapy after
major surgery reduces complications and

duration of hospital stay. A randomised, controlled
trial [ISRCTN38797445]. Crit Care 2005
Tote S, Grounds R. Performing perioperative
optimization of the high-risk surgical patient. Br J
Anaesth 2006; 97: 4–11.
Static : CVP, PAOP
LidCO
TEE


Anaesth 2006; 97: 4–11.
Static : CVP, PAOP
LidCO
TEE


Anaesth 2006; 97: 4–11.
Static : CVP, PAOP
LidCO
TEE


Anaesth 2006; 97: 4–11.
Optimisation of Patients in ICU
• Studied 109 critically ill patients in ICU, Mixture of surgical and medical patients.
• Treatment goals using dobutamine were:
• Oxygen delivery > 600 ml/min/m2.
• Oxygen consumption > 170 ml/min/m2.
• In those particular case, 17 pts received > 50 μg/kg/min of dobutamine and 68% of the
total group received NE
Treatment group
Treatment group
Control group
control group
Hayes, Timmins et al. N Eng J Med. 1994: 330; 1717
Optimisation of Patients in ICU
• In perioperative and posttrauma optimization, the main pathophysiologic problem

is hypovolemia, which easily can be reversed by standard resuscitation techniques
• ICU Septic patients already have MOD, septic cardiomyopathy, mitochondrial and
microcirculation dysfunction, administered high inotropics to increase
supranormal values had shown no benefits
Hayes, Timmins et al. N Eng J Med. 1994: 330; 1717
Individualized
Goal-Directed
Therapy
Hypotension is always a bad sign,
but shock is not always hypotension
Normal Blood Pressure- Normal Cardiac Normal Systemic Vascular
Mean Arterial Pressure Output Resistance
Normal Blood Pressure- High Systemic Vascular

Low Cardiac Output
Mean Arterial Pressure Resistance
Normal Blood Pressure- High Cardiac Output Low Systemic Vascular

Mean Arterial Pressure = Output Resistance

Low Cardiac Output

Mean Arterial Pressure = Output x Resistance

Low Cardiac Output

Normal Blood Pressure-

Mean Arterial Pressure = Low Cardiac Output
High Systemic Vascular
Resistance
Preload ⬇︎: Hypovolemia, hemorrhage

Contractility ⬇︎ : cardiac failure


Mean Arterial Pressure = Low Cardiac Output x High Systemic Vascular
Resistance
Preload ⬇︎: Hypovolemia, hemorrhage Compensatory response



Resistance


= High Cardiac Output Low Systemic Vascular
Resistance
Compensatory response

Resistance


= High Cardiac Output x Low Systemic Vascular
Resistance
Septic Shock
Reperfusion Injury
Compensatory response Anesthetics effect

Resistance


= High Cardiac Output x Low Systemic Vascular
Resistance
Septic Shock
Reperfusion Injury
Compensatory response Anesthetics effect
Preload Low Normal High

(CVP,PCWP)
Cardiac output
Low Op5mise fluid, then Inotropes Inotropes, vasodilator,
Consider inotropes diure5cs
Normal Op5mise fluid Monitor Monitor, consider
vasodilators, diure5cs
High Op5mise fluid Monitor Monitor, consider
vasodilators, diure5cs
Perioperative Goal-directed Therapy
Traditional Approach for Moderate Risk Surgery
MAP>65mmHg Urine Output >0.5ml/kg/hr Goal directed Therapy:
Target: Blood Pressure
CVP 8-12 mmHg CVP <8 mmHg (MAP 65-90), BIS 40-60
Intervention :
Anesthetic dose, Fluid
Fluid challange Vasoactives
Stress response
MAP>65 mmHg CVP 8-12 mmHg
Fluid challange
Fluid challange
Vasoactives
Observe Re-evaluate
1. OVERLOAD
Premed BIS 65 2. INTRAOP AWAKENING INCREASE
VO2 OVER DO2: Oxygen debt
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
70 Intubation Bowel/
Prep Incision Vasc
0.0
60 clamping/ Recovery 0.5
Anxiety Sleep Peritonel bleeding
MAP traction ICU MAC
Duration of surgery Modified from Mayer et al. Critical Care 2010, 14:R18
George 2014
YES Target: Blood Pressure
Intervention :
Stress response
Fluid challange
Fluid challange
Vasoactives
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
YES Target: Blood Pressure
Intervention :
Stress response

YES
Fluid challange
Fluid challange
Vasoactives
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
YES NO Target: Blood Pressure
Intervention :
Stress response

YES
Fluid challange
Fluid challange
Vasoactives
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
Intervention :
Stress response

YES NO
Fluid challange
Fluid challange
Vasoactives
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
Intervention :
Stress response

YES NO
Fluid challange
Fluid challange
NO Vasoactives
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
Intervention :
Stress response

YES NO YES
Fluid challange
Fluid challange
NO Vasoactives
YES
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
Intervention :
Stress response

YES NO YES
Fluid challange
Fluid challange
NO Vasoactives
YES
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
Intervention :
Stress response

YES NO YES
Fluid challange
Fluid challange
NO Vasoactives
YES
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
Intervention :
Stress response

YES NO YES
Fluid challange
Fluid challange
NO Vasoactives
YES
Observe Re-evaluate
1. OVERLOAD
90 BIS 45 BIS 55
80 BIS 75 1.0
1.5
Prep Incision Vasc
0.0
George 2014
Individualized Approach for High-Risk Surgery
Lactate >1,
CI ≥ 2.5 L/min ScvO2 <70%
Oxygen YES NO NO
Delivery
MAP SVI < 35 ml/min SVI > 35 ml/min
>65mmHg <65mmHg SVV<12 SVV<12

Stress response
SVI>35 ml/min Vasopressor Fluid challange Dobutamin Dobutamin
MAP >65mmHg SVI > 35 ml/min CI ≥ 2.5 L/min

NO YES NO NO YES
Vasopressor Fluid challange Dobutamin
5
Lactate >1,
3 ScvO2 <70%
2.5 Observe Re-evaluate

CI 1. OVERLOAD
CI, MAP tissue oxygenation
Premed 2. INTRAOP AWAKENING INCREASE
VO2 OVER DO2: Oxygen debt normal
90 60
Bi-spectral Index
40 2.0
Prep Incision Vasc 1.5
60 clamping/ Recovery
Anxiety Sleep Peritonel bleeding 0.5
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Lactate >1,
Oxygen YES NO NO
Delivery

Stress response

NO YES NO NO YES
5
Lactate >1,
3 ScvO2 <70%

CI 1. OVERLOAD
90 60
Bi-spectral Index
40 2.0
George 2014
Case
• A man underwent closure of thoracic
wound due open chest drainage caused by
mediastinitis for 2 weeks in the ICU
CO ScvO2
5.0 74
Derived Value Calculator
Cl 4/10/2012SV
– 11:31:46 AM SVR
2.9 52 1014
l/min/m2 ml/b dyne-s/cm5
SVV SVI SVRI
15 30 1899
% ml/b/m2 dyne-s-m2/cm5
9/8/2011
11:32:00 AM
CO ScvO2
5.0 74
4/10/2012 – 11:31:46 AM
Entries Derived
CVP = 4 mmHg DO2 = 658 ml O2/min
SpO2 = 100% DO2l = 432 ml O2/min/m2
PaO2 = 158 mmHg SVR = 1014 dyne-s/cm5
HGB = 10.3 g/dl SVRI = 1899 dyne-s/cm5
CO = 5.0 l/min
MAP = 62 mmHg
Return
9/8/2011
Alert Oximetry: SQI = 4 11:40:00 AM
• Dilakukan loading crystaloid 500cc +
colloid HES 130/0.4 sebanyak 250 cc
dalam 30 menit
CO ScvO2
7.5 74
Cl 4/10/2012SV
– 11:31:46 AM SVR
4.4 94 964
l/min/m2 ml/b dyne-s/cm5
SVV SVI SVRI
9 55 1638
% ml/b/m2 dyne-s-m2/cm5
9/8/2011
11:57:00 AM
CO ScvO2
7.5 74
4/10/2012 – 11:31:46 AM
Entries Derived
CVP = 11 mmHg DO2 = 987 ml O2/min
SpO2 = 100% DO2l = 548 ml O2/min/m2
PaO2 = 158 mmHg SVR = 964 dyne-s/cm5
HGB = 10.3 g/dl SVRI = 1638 dyne-s/cm5
CO = 7.5 l/min
MAP = 86 mmHg
Return
9/8/2012
Alert Oximetry: SQI = 4 11:57:00 AM
Normal heart
SVV
13% Line of reference
Stroke Volume
LVEDV (mL)
Preload
Normal heart
SVV
SVV
Stroke Volume
15 %
LVEDV (mL)
Preload
Normal heart
SVV Preload-‐independence:
If CO and BP low à no more
9 % fluid, need vasoactive
SVV
SVV
Stroke Volume
15 %
Preload-‐dependence:
If CO or BP lowà need more fluid
LVEDV (mL)
Preload
Anesthesia target:

Adequate of Depth Of Anesthesia with BiSpectral Index
(40-60)
Haemodynamic Goal directed Therapy:
- Monitoring:
- Preload static: CVP, PAOP, GEDI
- Preload dynamic: SVV, SV, CI, PVI
- Met +DO2/VO2: Lactate/ScvO2
- Intervention :
- Fluid+Inotrope target CI >4.5
- Vasopresor target MAP>65
- PRC target DO2I >600 , lactate<1, ScvO2 >70%
The perioperative oxygen cascade indicated
therapies
to prevent postoperative complications
Jhanji S, Pearse RM The use of early intervention to prevent postoperative complications

Current Opinion in Critical Care 2009, 15:349–354
The perioperative oxygen cascade indicated
therapies
to prevent postoperative complications
Jhanji S, Pearse RM The use of early intervention to prevent postoperative complications

Current Opinion in Critical Care 2009, 15:349–354
Concept of Individualized Hemodynamic Optimization
Optimization Oxygen uptake

Microcirculation of oxygen consumption (mitochondrial function)
Goal Directed Therapy

(Perioperative haemodynamic optimization )
1. Optimization Optimization 2. Haemoglobin

(arterial oxygen content) of oxygen delivery concentration
3. Cardiovascular performance
(cardiac output)
1.Contractility 3.Afterload
(heart rate and valvular function)
2.Preload (coronary blood flow)
Perioperative haemodynamic therapy, Mukhail Y. Kirov et al. Curr Op Crit Care 2010



(cardiac output)



(cardiac output)



Respiratory support
Additional oxygen and physiotherapy 3. Cardiovascular performance
(cardiac output)



Respiratory support RBC transfusion
Additional oxygen and physiotherapy Blood saving tachnologies
(cardiac output)



(cardiac output)



(cardiac output)
Contractility (inotropes, beta-

blockers)
Heart rate and rhythm
(pacing,chronotropes, anti-arrytmics,
anesthetics/sedatives
Valvular function (repair, replacement)



(cardiac output)
Contractility (inotropes, beta- Fluid load (colloids or crystaloid)

blockers) Fluid removal (diuretics,
Heart rate and rhythm ultrafiltration, restrictive fluid
(pacing,chronotropes, anti-arrytmics, therapy)



(cardiac output)
Contractility (inotropes, beta- Fluid load (colloids or crystaloid) Vasopressor/vasodilators

blockers) Fluid removal (diuretics, Regional anaesthesia
Heart rate and rhythm ultrafiltration, restrictive fluid Intra-aortic baloon pump
Microvascular pressure (fluid load)(?)
Microcirculatory recruitmenr (vasodilator and
inhibitor of vasoconstriction)(?)
Rheology(anti-coagulant,antiaggregants)(?)



(cardiac output)

Microvascular pressure (fluid load)(?) Microvascular permeability (attenuation
Microcirculatory recruitmenr (vasodilator and of tissue oedema (?)
inhibitor of vasoconstriction)(?) Blood purification (e.g. CVVH, inhibitors
Rheology(anti-coagulant,antiaggregants)(?) of cytokines and mediators (?)



(cardiac output)

Hypovolemic
Shock in Trauma
Hypovolemic shock
• Hypovolemic shock can be defined as an acute

disturbance in the circulation leading to an imbalance
between oxygen supply and demand in the tissues, caused
by a decrease in circulating blood volume mostly due to
trauma and surgery
Causes of Hypovolemic
Shock
• Loss of Blood
• Internally—rupture of vessels, spleen, liver; extrauterine

pregnancy
• Externally—trauma; gastrointestinal, pulmonary, renal

blood loss
• Loss of Plasma
• Burn wounds; gastrointestinal losses (diarrhea, ileus,

pancreatitis)
• Loss of Fluids and Electrolytes
• Gastrointestinal and renal losses (uncontrolled diabetes

mellitus, adrenocortical insufficiency)
Pathophysiology of shock from
Macrocirculation to Microcirculation
➡︎preload ➡︎diastolic filling, ︎ventricular

➡︎diastolic filling diastolic function afterload
(e.g., tension ➡︎sistolic function
pneumothorax or (e.g., massive
pericardial pulmonary
tamponade) embolus)
myocardial depression
➡ systolic and diastolic function)
Microcirculation
myocardial damage
➡︎systolic and diastolic function
Macrocirculation
Pathophysiology of shock from
Macrocirculation to Microcirculation
➡︎preload ➡︎diastolic filling, ︎ventricular

➡︎diastolic filling diastolic function afterload
(e.g., tension ➡︎sistolic function
pneumothorax or (e.g., massive
pericardial pulmonary
tamponade) embolus)
myocardial depression
➡ systolic and diastolic function)
Microcirculation
myocardial damage
➡︎systolic and diastolic function
Macrocirculation
Diagnosing of Shock Types
Arterial hypotension
➡︎MAP
Sign of tissue hypoperfusion :
Brain : aletered mental status
Skin : mottled, clammy
Kidney : oligouria
Tachycardia
Elevated Lactate
➡︎MAP
Sign of tissue hypoperfusion :
Kidney : oligouria
Tachycardia
Elevated Lactate
➡︎MAP
Sign of tissue hypoperfusion : Circulatory shock
Kidney : oligouria
Tachycardia
Elevated Lactate
➡︎MAP
Kidney : oligouria
Tachycardia
Elevated Lactate
➡︎MAP
Skin : mottled, clammy Estimated cardiac output
Kidney : oligouria
Tachycardia
Elevated Lactate
➡︎MAP
Kidney : oligouria
Tachycardia
Elevated Lactate
➡︎MAP
Kidney : oligouria
Normal or High
Tachycardia
Elevated Lactate
➡︎MAP
Kidney : oligouria
Normal or High
Tachycardia
Elevated Lactate
➡︎MAP
Kidney : oligouria
Normal or High
Tachycardia
Elevated Lactate
Distributive
➡︎MAP
Kidney : oligouria
Normal or High
Tachycardia
Elevated Lactate
Distributive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Elevated Lactate
Distributive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Elevated Lactate
Distributive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Elevated Lactate CVP/Preload
Distributive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Distributive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low
Distributive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low
Distributive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low
Distributive hypovolemic
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low High
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low High
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low High
Distributive hypovolemic Cardiogenic
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low High
Distributive hypovolemic Cardiogenic
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low High
Distributive hypovolemic Cardiogenic Obstructive
➡︎MAP
Kidney : oligouria
Normal or High Low
Tachycardia
Low High
Distributive hypovolemic Cardiogenic Obstructive
Circulatory Shock Hemodynamic
Profile
+ ︎Base
Deficit
Profile
+ ︎Base
Deficit
Artiz ME. Circulatory shock;Vincent JL.Critical Care Medicine Textbook 6th ed, 2013
Profile
+ ︎Base
Deficit
Artiz ME. Circulatory shock;Vincent JL.Critical Care Medicine Textbook 6th ed, 2013
Pathophysiology in hemorrhagic shock
Sympatico-adrenegic reaction Central Venous Pressure ➡︎
Heart Vascular System

Tachycardia
Cardiac Contractility ︎ Peripheral Hypotension
Vasoconstriction
Cardiac Oxygen Consumption ︎ Tissue Perfusion➡︎
Oxygen Delivery ➡︎ Oxygen Consumption➡︎
Anaerobic metabolism︎ Tissue Acidosis
Cardiac Failure︎
Reactive Oxygen Radicals ︎ NO ︎
Immune System︎
Capillary Leakage, Tissue Edema︎
Innate Immunity Adaptive Immunity
Coagulopathy
Hyperinflammation︎ Coagulation factors ➡︎Platetelets ➡︎

Consumption ︎ Loss
Immunodepression
DIC Hyperfibrinolysis
J Trauma. 2004;57:898 –912.

Tachycardia
Vasoconstriction
Cardiac Failure︎
Immune System︎
Coagulopathy

Immunodepression
J Trauma. 2004;57:898 –912.

Tachycardia
Vasoconstriction
Cardiac Failure︎
Immune System︎
Coagulopathy

Immunodepression
J Trauma. 2004;57:898 –912.

Tachycardia
Vasoconstriction
Cardiac Failure︎
Immune System︎
Coagulopathy

Immunodepression
J Trauma. 2004;57:898 –912.

Tachycardia
Vasoconstriction
Cardiac Failure︎
Immune System︎
Coagulopathy Blood
Vicious
Hyperinflammation︎ Coagulation factors ➡︎Platetelets ➡︎ Cycle
Immunodepression
J Trauma. 2004;57:898 –912.

Tachycardia
Vasoconstriction
Cardiac Failure︎
Immune System︎
Coagulopathy Blood
Vicious
Immunodepression Hypothermia
J Trauma. 2004;57:898 –912.

Tachycardia
Vasoconstriction
Cardiac Failure︎
Immune System︎
Coagulopathy Blood
Vicious
J Trauma. 2004;57:898 –912.

Tachycardia
Vasoconstriction
Cardiac Failure︎
Immune System︎
Coagulopathy Blood
Vicious
Multiple Organ Failure
J Trauma. 2004;57:898 –912.
Oxygen debt - repayment in
hemorrhagic shock
Base Deficit (meq/L)

O2 debt Volume (ml)
Lactate (mmol/L)
Time from start hemorrhage (min)
Siegel JH, Fabian M, Smith JA, Kingston EP, Steele KA, Wells MR: Oxygen debt criteria
quantify the effectiveness of early partial resuscitation after hypovolemic hemorrhagic shock.
J Trauma 54:862Y880, 2003
hemorrhagic shock
Hemorrhage

O2 debt Volume (ml)
Lactate (mmol/L)
J Trauma 54:862Y880, 2003
hemorrhagic shock
Partial
Resuscitation
Hemorrhage

O2 debt Volume (ml)
Lactate (mmol/L)
J Trauma 54:862Y880, 2003
hemorrhagic shock
Partial
Resuscitation
Hemorrhage
2 hours delay

O2 debt Volume (ml)
Lactate (mmol/L)
J Trauma 54:862Y880, 2003
hemorrhagic shock
Partial
Resuscitation
Hemorrhage
2 hours delay

O2 debt Volume (ml)
Lactate (mmol/L)
O2 Debt
J Trauma 54:862Y880, 2003
hemorrhagic shock
Partial
Resuscitation
Hemorrhage
2 hours delay

O2 debt Volume (ml)
Lactate (mmol/L)
O2 Debt
Lactate
J Trauma 54:862Y880, 2003
hemorrhagic shock
Partial
Resuscitation
Hemorrhage
2 hours delay
Base Deficit

O2 debt Volume (ml)
Lactate (mmol/L)
O2 Debt
Lactate
J Trauma 54:862Y880, 2003
hemorrhagic shock
Partial Full
Resuscitation Resuscitation
Hemorrhage
2 hours delay
Base Deficit

O2 debt Volume (ml)
Lactate (mmol/L)
O2 Debt
Lactate
J Trauma 54:862Y880, 2003
Stages of Hemorrhagic Shock
Microcircula,on Macrocircula,on
↓DO2 = ↓Hb, ↓SaO2 or ↓CO
Micro and macro compensatory response s

to maintain BP and VO2 s5ll normal

Hypoperfusion begins: best 5me for interven5on like

supranormal DO2 or decreased VO2 (demand) ASAP
ia
sox
Dy
ck -‐

Sho

ia
sox
Dy
ck -‐

Sho
O2 Extrac(on

ia
sox
SvO2-‐ScvO2
Dy
ck -‐

Sho
O2 Extrac(on

ia
sox
SvO2-‐ScvO2
Dy
ck -‐

Sho
O2 Extrac(on
Lactate
Base Deficit
ia
sox
SvO2-‐ScvO2
Dy
ck -‐

Sho
O2 Extrac(on
Lactate
Base Deficit
too late for interven,on: hypotension and supranormal DO2 or decreased VO2 (demand) ASAP
cell damage was already occured
(early) Goal Directed Oxygen Balance in
Resuscitation hypovolemic shock
Trzeciak, Rivers, Critical Care 2005,9(suppl 4):S20-S26


Macrocirculation

Macrocirculation

Macrocirculation

Macrocirculation
Microcirculation

Macrocirculation
Microcirculation
Endpoints of
resuscitation
Preload assesment
Fluid challenge
Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of
circulatory shock. Anesth Analg 1979;S8:124
Guided by CVP (cmH2)) PAOP mmHg) Infusion
Start <8 <10 200 ml/10 mnt
<12 <14 100 ml/10 mnt
12 14 50 ml/mnt
During infusion ↑>5 ↑>7 Stop
After 10 min 2 3 Continue
2>↑ = 5 3>↑=7 Wait 10 min
↑>5 ↑>7 Stop
After waiting 10 min Still ↑>2 Still ↑>3 Stop
↑ =2 ↑ =3 Repeat
10 cm H20 = 7.3 mm Hg. CVP, central venous pressure; PAOP, pulmonary artery occlusion pressure
Hypovolemic shock; Parillo and Delinger, Critical Care Medicine Textbook, 2008
• Moderate level of evidence suggests that the IVC diameter is consistently low in
hypovolemic status when compared with euvolemic
American Journal of Emergency Medicine (2011)
• Meta-analysis of prospective studies reporting sonographic measurement of IVC
diameter and its relationship with volume status suggest its potential usability in
guiding fluid resuscitation in adult ED population under spontaneous ventilation
• Meta-analysis of prospective studies reporting sonographic measurement of IVC
diameter and its relationship with volume status suggest its potential usability in
guiding fluid resuscitation in adult ED population under spontaneous ventilation
During emergency department resuscitation, a decline in PetCO2 correlates with
decreases in noninvasive CO in emergently intubated trauma patients.
Decreasing PetCO2 and declining NICOM CO are associated with
hemodynamic instability, hemorrhage, abnormal pupils, and death.
Dunham et al. BMC Anesthesiology 2013, 13:20
The study indicates that NICOM CO and End-Tidal CO2
values are clinically discriminate the progressive of major
blood loss
Dunham et al. BMC Anesthesiology 2013, 13:20
Shock Classification in Trauma
Education of ATLS 2008
EBL Based on Patient’s Initial Presentation
Responses to initial fluid resuscitation




Blood Pressure - Mean Arterial Pressure
in Trauma
Fluid Resuscitation
Permissive Hypotension and Hemorrhagic Shock
Mortality (%) and level of MAP
80%
60%
40%
20%
0%
40 mmHg 60 mmHg 80 mmHg
Stern et al Ann Emerg Med 1993
Prehospital Hypotension and Outcome
in Trauma
• Register of Ann Arbor Seattle USA 19 409 patients 2373 hypotension
70.0000 Mortality
Blunt
Penetrating 52.5000
35.0000
17.5000
0
120 + 120-90 90-60 60-0 Sistolic Arterial Pressure
Prehospital Hypotension = Predictive Factor of Mortality in Trauma

Arbabi et al J Trauma 2004 , 56 1029
Permissive Hypotension for
Uncontrolled Hemorrhage
• Strong clinical arguments but less clinical evidences

• Indirect arguments
• SBP : 70-90 mmhg
• SBP : 70-90 mmHg if no head trauma (modulate

according to age and underlying disease)
• MAP : 40 mmHg until bleeding is controlled and then
80 mmHg
• SBP : 120 mmHg in case of head and / or medullar
trauma
Estimated Blood Loss and Transfusion based on

Patient’s Initial Presentation and vitals sign

?
A New Proposed Classification Using
Tissue Oxygenation Parameter
A New Proposed Classification Using
Tissue Oxygenation Parameter
Hypoperfusion occurs despite normal blood pressure
Parameter of anaerobic metabolism more reliable
detecting hypoperfusion than Blood Pressure
Parameter of anaerobic metabolism more reliable
detecting hypoperfusion than Blood Pressure
Goal-directed therapy
Guidelines for Treatment of
Hypovolemic Shock
1. Insert large-bore intravenous catheter; perform laboratory investigations
(crossmatching, Hb, Ht, Tr, Elecrolyte, ABG and pH, lactate, coagulation, transaminase
and albumin. Watch for need to supply oxygen, intubation, or artificial ventilation
2. Resuscitation with fluids is done at a ratio of two thirds crystalloid,

one third colloid fluid. At >25% loss of blood volume, give erythrocyte
concentrates; at >60% loss, also give fresh frozen plasma (e.g., after about four
erythrocyte concentrates and earlier if liver function is disturbed). In case of
polytransfusions (>80% loss) and platelet counts <50 , platelet suspensions should be
given. Massive red blood cell transfusion is preferably performed via microfilter.
3. Diagnose and treat underlying cause, concomitantly with guideline

no. 2.
Supranormal value
Cardiac index (CI) 4.5 L/min/m2
Oxygen delivery (DO2I) 600 ml/min/m2
Oxygen consumption (VO2I) 170 ml/min/m2
Shoemaker et al Crit Care Med 1982: 10; 398.

Shoemaker et al Am J Surg 1983: 1; 43.
Shoemaker et al Chest 1988: 94; 1176
Vincent protocol, 2005
Pinsky MR, Vincent JL: Let us use the PAC correctly and only when we need it. Crit Care Med 2005;33:1119-1122
SVO2
Normal
(≥79%)
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
SaO2 Low SaO2 Normal (95%)
(Hypoxemia) (↑ O2ER)
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
↑ PEEP
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
↑ PEEP Cardiac Output
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
Hemoglobin
>8 g/dL
Stress, anxiety, pain
(High VO2)
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
Hemoglobin
>8 g/dL
Stress, anxiety, pain
(High VO2)
Analgesic
Sedation
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
Hemoglobin
>8 g/dL <8 g/dL

Stress, anxiety, pain Anemia
(High VO2)
Analgesic
Sedation
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
Hemoglobin PAOP-CVP
>8 g/dL <8 g/dL >18 mm Hg

Stress, anxiety, pain Anemia Myocardial
(High VO2) dysfunction
Analgesic Blood
Sedation transfusion
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
Hemoglobin PAOP-CVP
>8 g/dL <8 g/dL >18 mm Hg <18 mmHg

Stress, anxiety, pain Anemia Myocardial Hypovolemia
Analgesic Blood
Dobutamine
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
Hemoglobin PAOP-CVP

Analgesic Blood
Dobutamine Fluid challenge
SVO2
Normal Low
(≥79%) (<70%)
pCO2 gap<6
Blood Lactate
Oxgen therapy
High Low
(>2.5 L/min/m2) (<2.5 L/min/m2)
SVV-PPV
Hemoglobin PAOP-CVP IVC colapsibility

Analgesic Blood
Dobutamine Fluid challenge
Pearce protocol, 2005
Pearse RM, Dawson D, Fawcett J, et al: Early goal-directed therapy after major surgery reduces complications and
duration of hospital stay. Crit Care 2005;9:687-693
Trauma/hemorrhage
Elevated lactate
Supplemental O2 ± ETI
with mech ventilation (if
necessary) Begin fluid resuscitation (initial bolus of
Target SaO2 of ≥ 95% at least 20 ml/kg crystalloid, to be
continued with colloids, red cell
concentrates and coagulation factors
Hypovolemic shock SBP remains < 90 mmHg or

MAP remains < 65 mmHg;
lactate does not fall
management protocol
Filling pressure
<8 mmHg Insert
Fluid boluses CVP or PA
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
Vasopressor (norepinephrine
MAP
or dopamine prefered)
MAP ≥ 65
*If PAC is used a mixed venous Os sat is NO
ALL Goals
an acceptable surrogate, and 65% would
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Trauma/hemorrhage
Elevated lactate

management protocol
Filling pressure
<8 mmHg Insert
Cath
Filling pressure
> 8 mmHg
Dobutamine/ < 70%
Dopamine ScvO2*
< 70%
MAP < 65
MAP
MAP ≥ 65
ALL Goals
achieved?
be the target
Fluid Resuscitation
in Trauma Patients
In the 1950s and 1960s much trauma
research focused on high volume
resuscitation
In the 1980s, the concept of limited fluid
resuscitation returned. Animal models
focused on uncontrolled hemorrhage, a
more realistic model.
Crystalloid versus Colloid
Conclusion; For hypotensive patients with
penetrating torso injuries, delay of aggresive fluid
resuscitation until operative intervention
improves the outcome
Case
• A 19-year old male was stabbed in the abdomen the patient

awake, but sluggish.
• He is speaking and his airway appears patent. Breath sounds

are equal bilaterally.
• Peripheral pulses are palpable, and on close inspection, the

wound appears to be bleeding only minimally.
• Chest x-ray is normal. The trauma surgeon perform initial

USG FAST (Focus Assessment of Sonography in Trauma)
examination show intraabdominal free fluid level.
• The patient’s initial vital signs are: heart rate of 140
beats per minute, blood pressure of 80/50 mm Hg,
respiratory rate of 20 breaths per minute, temperature
of 97°F (36.1°C), and SpO2 of 100% on room air.
• One 18-G IVs are placed, lab work is drawn,
• The patient looks pale, anaemic and starts to

have shortness of breath and become
somnolence.
What is the
suspected injury ?
What is the first
resuscitation action
should be done?
Trias of death in trauma
• Airway -Ventilation : O2
FM 6lt/min
• Circulation : 2 large
bore IV, fluid
resuscitation 1-2 litres
• Crystalloid or colloid ?
• Transfusion ?
What is the laboratory
examination required ?
• Complete blood count
• Blood type and crossmatch
• Coagulation profile, including prothrombin time (PT), partial

thromboplastin time (PTT), and international normalized ratio (INR)
• Basic metabolic panel : Blood sugar level, Blood gas analysis,

electrolytes
• Toxicology studies, including alcohol level and drug screen, as

appropriate
• Pregnancy test, as appropriate
• Lactate level and base deficit (usually, both can be ascertained

from a blood gas syringe)
Lab findings
• Hb 6.0/ Ht 15/ Leu 12.000/ Plt 70.000
• Blood type and crossmatch : gol. AB
• Coagulation profile : prothrombin time (PT) 2x, partial

thromboplastin time (PTT) 2.5 x, and international
normalized ratio (INR) 2.5x
• Basic metabolic panel : Blood sugar level 150, Blood

gas analysis 7.211/26.9/175/-8.1/18.9/98.8, electrolytes
141/3.82/105
• Lactate level 5 and base deficit -8.1
21th century:
A New Approch in Trauma Resuscitation
Flowchart of initial management of traumatic hemorrhagic shock
Bouglé et al. Annals of Intensive Care 2013, 3:1
Fluid Resuscitation based on
Classes of shock by ATLS
Crystalloids
Crystalloids
Colloids
Crystalloids
Colloids
Blood transfusions
Fluid option
• Blood and components
• Crystalloid
• Colloid
• Hypertonic solution
Isotonic crystalloids
••Advantages
Cheap
• Easy to store and warm
• Established safety
• Predictable rise in cardiac output
••
Disadvantages14
Large volumes needed
• Dilutional coagulopathy
• Increase cytokine activation7
• No oxygen carrying capacity
• May Increase ICP

Composition of IV
Crystalloid
Na Cl K Ca Buffer pH
Plasma 141 103 4-5 5 Bicarb 7.4
0.9%NS 154 154 ---- ---- ---- 5.7
LR 131 111 2 3 Lactate 6.4
LR vs NS
• Patients undergoing aortic aneurysm repair
• NS
• More volume (~500-1000ml)
• Hyperchloremic acidosis
• Swine bled via liver injury & resuscitated to MAP 90mmHg

• NS
• More volume
• Hyperchloremic acidosis
Waters 2001 (Aneth Analg)
Todd (J. Trauma 2007; 62:636-9)
LR vs NS
• Conclusion

•
No mortality difference
• LR
• Lower overall volume
• More buffering capacity
• NS
• Hyperchloremia acidosis
• Probably no difference for prehospital or early fluid resuscitation.
Colloids
• Proposed Benefits
• Smaller volume
• Less pulmonary edema
• Stays in the intravascular space
• Quicker return to normal
hemodynamics
• Smaller package
• Antioxidant and antinflammatory effects
Colloids
• •Disadvantages
Transmission of diseases
• Increased bleeding
• Hypersensitivity reactions
• Renal failure
• Accumulation
• Taken up by RES
• Dose limit (20-33mL/kg)
• Cost
Hypertonic Saline
• Rapid plasma volume expansion
• Pull of fluid to vascular space secondary to increased
concentration gradient
• Decreases ICP
• Potential benefits in TBI patients
• Military use
• Weighs less
• 1 liter NS bag=2744 cm3 in volume and 1.1 kg
• Storage space for helicopters and ground ambulances
Hypertonic Saline
• Adverse effects
• Hyperosmolar coma
• Hypernatremia
• Seizures
• arrhythmias
• Tissue necrosis
• Allergic reactions
Hypertonic Saline
• Hypertonic saline
• 7.5% or 7.2%
• Dextran 70 (RescueFlow) or HES (HyperHAES)
• Osmolarity 2500 mOsm/liter
• Na+: 1200 mmol/liter
• Total volume 250ml
Natural Colloids :
Albumin
• SAFE trial 2004 (N Engl J Med 2004)
•
Double blind RCT, 7000 pts, 16 ICUs, 18 month period
• 4% albumin v 0.9% normal saline
• First 4 days volume albumin to saline (1:1.4)
• No difference in 2 groups in 28 all day cause mortality
• Sub group analysis: difference between trauma and sepsis
patients
• RR of death pts with severe sepsis= 0.87
• Overall trauma mortality higher for albumin v saline (13.5%
v 10%)
• TBI increase in mortality
Bio-physiology of Colloids
Bio-physiology of Colloids
Crystalloid vs colloid
distribution
Fluids Plasma Interstitial Intracellular
Alb5% 1000
Expafusin 6% 1000
Poligeline 700 300
Dextran 40 1600 -260 -340
Dextran 70 1300 -130 -170
NaCl 0.9% 200 800
NaCl 1.8% 320 1280 -600
NaCl 0.45% 141 567 292
RL 200 800
D5% 83 333 583
Vasoactives
Baseline Characteristics Dopamine Norepinephrine
Baseline Characteristics Dopamine Norepinephrine
Result
• In summary, although the rate of death did not differ significantly between the group of
patients treated with dopamine and the group treated with norepinephrine, this study
raises serious concerns about dopamine, as compared with norepinephrine, was
associated with more arrhythmias and with an increased rate of death in the
subgroup of patients with cardiogenic shock
Transfusion
trigger
Transfusion guidelines
Fluid Choice and Blood for Resuscitation
Progressive laboratory assessment of hemoglobin level and hemostasis
50% 100% 150% 200%

Onset of % of total blood volume replaced
hemorrhage
Fluid Choice for Resuscitation in Trauma. Joachim Boldt, International TraumaCare (ITACCS).Vol. 18, No. 1, 2008
50% 100% 150% 200%

hemorrhage
50% 100% 150% 200%

hemorrhage
Crystalloid +
colloid
50% 100% 150% 200%

hemorrhage
Red blood cells
Crystalloid +
colloid
50% 100% 150% 200%

hemorrhage
Fresh Frozen Plasma
Red blood cells
Crystalloid +
colloid
50% 100% 150% 200%

hemorrhage
Platelets
Fresh Frozen Plasma
Red blood cells
Crystalloid +
colloid
50% 100% 150% 200%

hemorrhage
How should the
coagulopathy of trauma
be managed?
Management of bleeding following major trauma: an
updated European guideline
Critical Care 2010
Critical Care 2010
I. Initial
II. Diagnosis and IV. Management of V. Tissue
resuscitation and III. Rapid control of
monitoring of bleeding and oxygenation, fluid
prevention of bleeding
bleeding coagulation and hypothermia
further bleeding
Critical Care 2010
I. Initial
further bleeding
Coagulation
management
Critical Care 2010
I. Initial
further bleeding
Coagulation
management
Coagulation support
Calcium
Fresh frozen plasma
Platelets
Fibrinogen or cryoprecipitate
Antifibrinolytic agents
Recombinant activated coagulation factor VII
Protrombin complex concentrate
Desmopressin
Antithrombin III
Critical Care 2010
I. Initial
further bleeding
Critical Care 2010
I. Initial
further bleeding
Critical Care 2010
I. Initial
further bleeding
RESUSCITATION
Critical Care 2010
I. Initial
further bleeding
VOLUME REPLACEMENT
A target systolic blood pressure of
80-100 mmHg should be employed RESUSCITATION
until major bleeding has been stopped
in the initial phase following trauma
without brain injury
Critical Care 2010
I. Initial
further bleeding
VOLUME REPLACEMENT
FLUID THERAPY
Crystalloid should be applied initially to treat the
bleeding trauma patient. Hypertonic solutions may be
considered during initial treatment. The addition of
colloids may be considered within the prescribed
limits for each solution in haemodynamically unstable
patients.
Critical Care 2010
I. Initial
further bleeding
VOLUME REPLACEMENT
FLUID THERAPY
NORMOTHERMIA
Early application of meassures to
patients.
reduce heat loss and warm the
hypothermic patient should be
employed to achieve and maintain
normothermia.
Critical Care 2010
I. Initial
further bleeding
VOLUME REPLACEMENT
FLUID THERAPY
NORMOTHERMIA
Early application of meassures to ERYTHROCYTES
patients.
reduce heat loss and warm the Treatment should aim to
hypothermic patient should be achieve a target Hb of
employed to achieve and maintain 7-9 g/dl.
normothermia.
The main pathophysiological mechanisms involved in
acute traumatic coagulopathy and transfusion strategy
The main pathophysiological mechanisms involved in
acute traumatic coagulopathy and transfusion strategy
Protocols of Massive Transfusion
Case
• The patient who is resuscitated to MAP 65 mmhg
with 2 litres crystalloid.
• The MTP is activated, the patient is given a dose

of tranexamic acid 1 gr boluses
• The first installments of PRBCs 500 cc and FFP

500 cc and TC 5 units are given to the patient
through a fluid warmer, with improvement of
blood pressure to 90/60 mm Hg.
• The surgeon arrived and agreed to take the

patient to the operating room.
Question & Discussion
Objectives
• DO2-VO2, oxygen debt concept
• Static Dynamic Parameters
• Principle of heart-lung interaction
monitoring
• Assessment of volume/fluid
responsiveness
• Macrocirculation - Microcirculation circle
concept
• Resuscitation end-points
Concept of oxygen debt
Uptake in the Lung Oxygenation PaO2
Carrying capacity
Carrying capacity Haemoglobin
Carrying capacity Haemoglobin SaO2
CaO2
CaO2
Delivery
CaO2
Delivery
CaO2
Delivery Cardiac Output
CaO2
Delivery Cardiac Output Flow rate
CaO2
Carrying capacity Haemoglobin SaO2 DO2
CaO2
Organ distribution
CaO2
Organ distribution
CaO2
Organ distribution Autoregulation
CaO2
Diffusion
CaO2
Diffusion
CaO2
Diffusion
Distance
CaO2
Diffusion
Distance
CaO2

Mikrosirkulasi
Diffusion
Distance
CaO2

Mikrosirkulasi
Diffusion
Distance
Cellular use
CaO2

Mikrosirkulasi
Diffusion
Distance
Cellular use
CaO2

Mikrosirkulasi
Diffusion
Distance
Cellular use Mitochondria
ATP = energy
CaO2

Mikrosirkulasi
Diffusion
Distance VO2
ATP = energy
CaO2
Oxygen Supply (DO2) = DO2
Carrying capacity Haemoglobin SaO 2
SaO2 x Hb x CO

Mikrosirkulasi
Diffusion
Distance VO2
ATP = energy
CaO2
Oxygen Supply (DO2) = DO2
Carrying capacity Haemoglobin SaO 2
SaO2 x Hb x CO

Mikrosirkulasi
Oxygen Consumption
Diffusion
Distance (VO2) = VO2
(SaO2-SvO2) x Hb x CO
ATP = energy
CaO2
Cardiac Output (CO) X (SaO2 or SpO2) X Hemoglobin (Hgb)
Heart Rate
X Stroke Volume Routinely measured
(HR) (SV)
Advance monitoring
Preload Afterload Contractility
CaO2
Cardiac Output (CO) X (SaO2 or SpO2) X Hemoglobin (Hgb)
Heart Rate
X Stroke Volume Routinely measured
(HR) (SV)
Advance monitoring
Preload Afterload Contractility
SaO2
Carrying capacity Hb
DO2=
Haemoglobin
CO.Hb.SaO2
Delivery Cardiac Output Stroke Volume.HR
ScvO2
Organ distribution Autoregulation Lactate, BE

Microcirculation
:
Diffusion Distance CO2 gap,
tonometri,
VO2 =
EVLW CO.Hb.(O2ER)
Cellular use Mitochondria Cytochrome-C
Apoptosis
marker
Static Dynamic Parameters
1. OVERLOAD
2. INTRAOP
Traditional Fluid Fluid Fluid Fluid + PRC? AWAKENING à
INCREASE VO2 OVER
practice DO2: Oxygen debt
BIS 45
90 BIS 45 1.5
BIS 55 BIS 1.0 MAC
80
MAP
BIS 55-‐65 0.5

65 0.0
70
60
Goal directed Therapy:
Stress response
Target: Blood Pressure

Intervention : Anesthetic dose and Fluid
Premed
Intubation
Incision
Surgery
Another
Bowel/
Vasc clamping/ Recovery Chapter
Prep bleeding
Anxiety
Sleep Peritonel
traction ICU
Duration of surgery George 2014
The Concept of monitoring haemodynamic and BIS in Perioperative Goal-‐directed
Therapy in high risk surgery
Vasopressor 20-‐30 minutes

Inotrope
Fluid
Oxygen Delivery
Lactate <1,
SVV/PPV high Observe
ScvO2 >70%
CI low CI, MAP
SVV/PPV low
normal Lactate >1, Transfusion/
SVR low ScvO2 <70% PEEP
Anesthetic agents
Macrodynamic Tissue Oxygenation
60
Bi-‐spectral Index
40
Stress response
Premed
Recovery
Bowel/
Vascular
Anxiety clamping/
Peritonel
Intubation Incision traction Bleeding
Duration of surgery

• Preload monitoring :
1. Static indexes of preload

2. D ynamic indexes of
– Pressure:
preload
• CVP
(fluid responsiveness ) :
• PAOP
– Volume (TD & Echo): –Pressure:
• GEDV/ITBV •SPV
• CO, SV (stroke volume)
• LVEDA (Echo)
•PPV
–Volume :
•SVV
• Preload responsiveness :

– Pressure:
preload
• CVP
• PAOP
• LVEDA (Echo)
•PPV
–Volume :
•SVV
baseline value

– Pressure:
preload
• CVP
• PAOP
• LVEDA (Echo)
•PPV
–Volume :
•SVV
fluid loading
baseline value changes in
Stroke Volume

– Pressure:
preload
• CVP
• PAOP
• LVEDA (Echo)
•PPV
–Volume :
•SVV
fluid loading
Stroke Volume

– Pressure:
preload
• CVP
• PAOP
• LVEDA (Echo)
•PPV
–Volume :
•SVV
fluid loading
Stroke Volume

– Pressure:
preload
• CVP
• PAOP
• LVEDA (Echo)
•PPV
–Volume :
•SVV
fluid loading
Stroke Volume
Stroke Volume Variation (SVV)
In mechanically ventilated patients without arrhythmia,

SVV reflects the sensitivity of the heart to the cyclic changes in cardiac
preload induced
by mechanical ventilation
SVV can predict whether stroke volume will increase with volume
expansion

preload induced
expansion
Mechanical
Breath
Inspiratio Expiratio
Thursday, November 6, 14 n n

preload induced
expansion
Arterial Wave
Mechanical
Breath

preload induced
expansion
SVMax
Arterial Wave
Mechanical
Breath

preload induced
expansion
SVMax SVV = (SV max – SV min) / SV mean
Arterial Wave
SVMin
Mechanical
Breath
Large SVV
Large SVV
Large SVV
Hypovolemia, need volume

loading
Large SVV

loading
Low SVV
Large SVV

loading
Low SVV
Large SVV

loading
Low SVV
Normovolemia, need vasoactive

Normal heart
Stroke Volume
LVEDV (mL)
Preload
Normal heart
Stroke Volume
LVEDV (mL)
Preload
Normal heart
SVV
Stroke Volume
LVEDV (mL)
Preload
Normal heart
Preload-‐independence:
If CO and BP drop à need
vasoactive
SVV
Stroke Volume
LVEDV (mL)
Preload
Normal heart
Preload-‐independence:
If CO and BP drop à need
vasoactive
SVV
Stroke Volume
Preload-‐dependence:
If CO or BP drop à need more fluid
LVEDV (mL)
Preload
Normal heart
SVV
10%
Stroke Volume
LVEDV (mL)
Preload
Normal heart
SVV
10%
Stroke Volume
SVV
45 %
LVEDV (mL)
Preload
Normal heart
SVV
10%
SVV
Stroke Volume
18 %
SVV
45 %
Preload-‐dependence
LVEDV (mL)
Preload
Normal heart
SVV
SVV 9 %
10%
SVV
Stroke Volume
18 %
SVV
45 %
LVEDV (mL)
Preload
Normal heart
SVV
SVV 5 %
SVV 9 % Preload-‐independence
10%
SVV
Stroke Volume
18 %
SVV
45 %
LVEDV (mL)
Preload

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Perioperative Goal-Directed

• Perioperative Hemodynamic and Shock

Post surgery in the ICU :

Jhanji et al Anaesthesia 2008; 63(7): 695-701

Jhanji et al Anaesthesia 2008; 63(7): 695-701

Less than 1/3 of high-risk

Jhanji et al Anaesthesia 2008; 63(7): 695-701

Database size 144,370 31,705 12,781 152,523

Overall 10,424 3,246 3,247

Why are outcomes

Database size 144,370 31,705 12,781 152,523

Overall 10,424 3,246 3,247

Why are outcomes

Database size 144,370 31,705 12,781 152,523

Overall 10,424 3,246 3,247

AHA 2007 guidelines on perioperative

Bowel ischemia Bowel edema

Bowel ischemia Bowel edema

Bowel ischemia Bowel edema

Bowel ischemia Bowel edema

Bowel ischemia Bowel edema

• Tissue injury-induced inflammatory response

• The preexisting disease state

• Imbalance Tissue oxygen delivery DO2 and

Majority of postoperative complications :

• Tissue injury-induced inflammatory response

• The preexisting disease state

• Imbalance Tissue oxygen delivery DO2 and

Majority of postoperative complications :

1.34: oxygen-binding capacity of hemoglobin

OXYGEN DELIVERY (DO2)

OXYGEN DELIVERY (DO2)

NORMAL PHYSIOLOGIC STATE

OXYGEN DELIVERY (DO2)

NORMAL PHYSIOLOGIC STATE

OXYGEN DELIVERY (DO2)

Critical DO2 Values

NORMAL PHYSIOLOGIC STATE

OXYGEN DELIVERY (DO2)

Critical DO2 Values

OXYGEN DELIVERY (DO2)

Critical DO2 Values

High-risk Surgical Patients

OXYGEN DELIVERY (DO2)

Critical DO2 Values

High-risk Surgical Patients

OXYGEN DELIVERY (DO2)

Critical DO2 Values

High-risk Surgical Patients

OXYGEN DELIVERY (DO2)

Critical DO2 Values

High-risk Surgical Patients

OXYGEN DELIVERY (DO2)

Critical DO2 Values

High-risk Surgical Patients

OXYGEN DELIVERY (DO2)

Critical DO2 Values

High-risk Surgical Patients

Critical DO2 Values