Polytruma

December 2012 • Volume 11 5 • Number 6 www .anesthesia-analges ia.org 1263 Copyright © 2012 International Anesthesi a Research Society DOI: 10.1213/ANE.0b013e3182730d04 R ecommendations or the resuscitation o patients who have sustained blunt or penetrating trauma continue to evolve, especially or those patients who present with, or who develop, coagulopathy (dened as requiring more than 10 U o 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 or developing coagulopathy, partly because o the resuscitation-related dilu- tion o coagulation actors, including dilutional thrombocyto- penia. Two decades later, Bickell et al. 2 subsequently conducted a somewhat controversial prospective study demonstrating that the resuscitation o trauma victims with crystalloid fuids beo re hosp ita l a rriva l was asso ciat ed with incr ease d morbidity and mortality. The study was controversial because it was one o the early studies o prehospital patients who were randomly assigned to the “experimental” group or the conventional treat- ment group without their consent but with IRB approval o the study. 3 Without societal willingness to approve such studies, the care o patients in extremis who are unable to consent (as most o us understand consent) to enrollment in a prospective randomized study would have been signi cantly delayed. As it was, and as it is with most such results, the time (the hysteresis) beo re the resul ts o the study were inco rpor ated into clinical practice was more than 10 years. During the early days o Operation Enduring Freedom and Operation Iraqi Freedom, orward surgical teams and personnel at combat support hospitals cared or a number o soldiers who developed abdominal compartment syn- drome, which arises secondary to a number o actors, one o which is the amount o crystalloid administered. On the basis o such observations and studies such as Bickell et al., 2 the current recommendations o the U.S. Military’s Joint Theater Trauma System advise clinicians to limit the amount o crystalloid used to resuscitate wounded soldiers. 4 Other studies conducted during the past decade, including TRICC, 5 SAFE, 6 and FOCUS, 7 have aected 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 transusion threshold, the hemo- globin level at which patients are administered RBCs, has gone rom 10 g/dL to 8 g/dL and is now hovering closer to 7 g/dL, even or patients who are at higher risk o having coronary artery disease. 7 The SAFE study demonstrated that resuscitation with a colloid (albumin) o patients once they were admit- ted to the intensive care unit (ICU) did not aect outcome. 6 The 6S study (Scandinavian Starch or Severe Sepsis/Septic Shock Trial) 8 demonstrated that patients with severe sepsis resusci- tated with hydroxyethyl starch (130/0.42) had an increased risk o 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 o 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 o this year, and though the investigators did not nd an increased incidence o death at 90 days, they did conrm the results o the 6S study in that more patients who received hydroxyethyl starch required renal replacement therapy. However, i these studies show that albumin is no better than crystalloid and that hydroxyethyl starch may be worse than crystalloid, albeit when inused in a slightly di erent population, that is, patients in ICUs and not patients requiring resuscitation in a eld environment, emergency department, or operating room, perhaps crystalloid is not the culprit some thought it to be; i nst ead, perhap s it is t he “v olu me” o fui d adm inis ter ed to ble edin g pa tie nts t hat resu lts i n coa gul opa thy . I ha ste n to p oint out that the previously cited studies were conducted in the prehospital environment or in the ICU or during the perioperative period not speci cally limited to the operating room in actively ble edin g pa tients . In t he la tte r set tin g, a s lig htl y di e ren t re sus - citation strategy is the norm. 10 However, when the results o all o these studies are taken together, many contend that the net results support the concept o damage-control surgery or resuscitation. 11 The most important goal o resuscitation is to stop the ble edin g r om w hat ever sou rc e to avo id t he ne ed t o administer large volumes o any fuid. When fuid must be administered, one should replace what was lost (i.e., ideally, with whole blood i many trauma surgeons had their preerence) 12 or as a ratio o pRBCs to resh rozen plasma o 1:1 13 or o pRBCs to resh rozen plasma to platelets o 1:1:1. 4 The latter observations have bee n cal led i nto q uestio n bec ause o t he su rvi val basi s inh ere nt in some o the observational studies that support a xed ratio o blo od pro duc ts whe n r esu sci tat ing coa gul opa thi c p ati ents. The reality, though, is that, even i the bleeding is stopped immediately and providers use whichever RBC product in From the Trauma and Critical Care Medicine, Landstuhl Regional Medical Center, Landstuhl Germany. Accepted or publication August 28, 2012. The author declares no conficts o interest. The opinions or assertions contained herein are the private views o the author and are not to be construed as ocial or as refecting the views o the Department o the Army or the Department o Deense. Reprints will not be available rom the author . Address correspondence to Michael J. Murray , MD, PhD, Landstuhl Regional Medical Center, CMR 402 Box 2564, APO AE 09180. Address e-mail to mi- [email protected] E EDITORIAL We Can’t Go Home Again: Advances in the Resuscitation of Patients with Polytrauma Michael J. Mur ray , MD, PhD

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Polytruma