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FluidResuscitationinTraumaticCriticallyIllPatientsAug21,2006Ri林殿閔PatternsofTraumaticInjuryPenetratinginjury–ongoingsignificantbloodlossisexpectedBluntinjury–bloodlossmaybeoccultorcontainedandsignificantorlimitedHeadinjury–maintenanceofcerebralperfusionpressureOthers:pediatricandobstetrictraumaShockDefinition:astateofreducedorganperfusionresultingintissuehypoxiaandorgandysfunctionS/S:fallingofBP,tachycardia,oligouria,decreasedmentalstatus,decreasedperipheralpulses,diaphoresisMaingoaloftherapy:rapidresuscitationwithre-establishmentoftissueperfusionusingfluidtherapyandvasoactivedrugsHemorrhagicshockAcuteresponse:

IncreasedcapillarypermeabilityReductioninbloodflowSympatheticcompensationbyperipheralvasoconstrictionElevatedIL-6andTNF-alphaTissuehypoperfusionandanaerobicmetabolism/acidosisAftersystemiccirculationisrestored,reperfusioninjuryduetofreeoxygenradicalsreleasedduringacutehypoxicstagemayoccur

TraumatichemorrhagicshockAcutestage:hemorrhagicshockMaybeaccompaniedwith:

Cardiogenicshock

NeurogenicshockObstructiveshockSepticshockTraumatichemorrhagicshockTraumatriadofdeathafterhemorrhagicshock:(1)Hypothermia(2)Acidosis(3)CoagulopathyTraumatichemorrhagicshockPhase1:Theperiodfrominjurytodefinite surgicalcareandhomeostasisPhase2:Theperiodduringandimmediately afterdefinitesurgicalprocedurePhase3:TheperiodinICUfollowing definitivecareandcharacterized byestablishedcriticalillnessPhase2:perioperativefluidmanagementItisunclearwhethertargetingcardiacoutputoroxygendeliverytospecificdefinedgoalsresultsinimprovedclinicaloutcomesMaximizedstrokevolumeusingfluidstitratedagainstameasureofbloodflowissupportedbylimitedavailabledataPhase2:perioperativefluidmanagementTheadditionofinotropestoachievespecificbloodfloworoxygendeliverygoalsmayconferadditionaladvantagebuttheavailabledataisnotconclusivePhase3:CriticalcarefluidmanagementFluidstrategiesaredirectedatrestoringorganfunctionafterthecombinedinsultofhypovolemichypoperfusion,surgeryandtraumainducedinflammatoryresponseMaintaininganormalcirculatingvolume(cardiacoutput)isapriorityTargetingoxygendeliverygoalshasbeendemonstratedtobeharmfulinestablishedcriticalillnessTraumaFluidResuscitationSeverityofhemorrhagicshockAgeCo-morbiddisorderInjurytypesConcurrentheadorspinalinjuryPulmonaryedemaTypesofFluidCrystalloidsolutionsColloidsolutionsGelatinsDextransHydroxyethylstarches(HES)Albuminandplasma-proteinfractionBlood&bloodsubstitutesCrystalloidsSolutionsinwaterofinorganicionsandsmallorganicmolecules,eitherglucoseorsodiumchloridebased.ColloidsKeycharacteristicsofartificialcolloidsMagnitudeanddurationofplasmavolumeexpansionHemorreologicalcharacteristicsHemostaticeffectsInteractionwithendothelialandinflammatorycellsAdversedrugreactionsCostAlbuminandplasma-proteinfractionHumanalbumin:anaturallyoccuringmonodipersecolloidFFPandplasma-proteinfraction:amorepolydispersehuman-derivedcolloidalsolutionwithsignificantamountsofhigher-MWproteins--globulinsBloodSubstitutes:hemoglobulinsolutionsAtanearlystageofdevelopmentandprobablysomewayfromroutineclinicaluseHBOC(Hemoglobic-basedoxygen-carryingcompounds)PBOC(Perflourocarbon-basedoxygen-carryingcompounds)H

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