What is the proper resuscitation strategy intraoperatively in trauma patients?

From the Guidelines

The proper intraoperative resuscitation strategy for trauma patients should follow a damage control approach, prioritizing the correction of the lethal triad of hypothermia, acidosis, and coagulopathy, with a balanced approach using permissive hypotension and early blood product administration in a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets for massive transfusion, as recommended by the most recent European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.

Key Components of Resuscitation Strategy

• Rapid establishment of adequate vascular access using large-bore IVs (14-16 gauge) or central venous catheters
• Initial fluid resuscitation with warmed balanced crystalloids like Lactated Ringer's at 1-2 L initially
• Permissive hypotension (maintaining systolic blood pressure around 80-90 mmHg) in patients with uncontrolled hemorrhage until definitive hemostasis is achieved, except in traumatic brain injury where cerebral perfusion must be maintained (target SBP >110 mmHg) 1
• Early blood product administration in a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets for massive transfusion, as supported by the PROPPR trial 1
• Tranexamic acid administration at 1g IV over 10 minutes followed by 1g over 8 hours if within 3 hours of injury

Monitoring and Adjunctive Therapy

• Continuous monitoring of core temperature and active prevention of hypothermia using fluid warmers, forced-air warming blankets, and heated humidified gases
• Regular assessment of coagulation status using point-of-care testing (thromboelastography or rotational thromboelastometry if available) to guide targeted component therapy
• Vigilant monitoring of acid-base status, electrolytes (particularly calcium), and hemodynamics, with vasopressors used judiciously only after adequate volume resuscitation

Considerations and Contraindications

• The concept of permissive hypotension is contraindicated in patients with TBI and spinal injuries, as well as in elderly patients with chronic arterial hypertension 1
• The use of colloid solutions, such as hydroxyethyl starch and gelatine, may impair coagulation and platelet function, and their use should be carefully considered 1

From the FDA Drug Label

Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines. Epinephrine may induce cardiac arrhythmias and myocardial ischemia in patients, especially patients with coronary artery disease, or cardiomyopathy

The proper resuscitation strategy intraoperatively in trauma patients involves:

• Correction of blood volume depletion as fully as possible before administering any vasopressor
• Administration of vasopressors such as norepinephrine (LEVOPHED) or vasopressin to increase blood pressure in cases of vasodilatory shock
• Use of epinephrine with caution, as it may induce cardiac arrhythmias and myocardial ischemia, especially in patients with coronary artery disease or cardiomyopathy
• Monitoring of blood pressure and titration of vasopressors to avoid excessive increases in blood pressure 2, 3, 4

From the Research

Proper Resuscitation Strategy Intraoperatively in Trauma Patients

• The proper resuscitation strategy intraoperatively in trauma patients involves the use of crystalloids, blood products, and other interventions to maintain adequate blood pressure and perfusion of vital organs 5, 6.
• Current trauma resuscitation guidelines recommend giving an initial crystalloid bolus as first line for resuscitation, with the goal of maintaining a balance between crystalloid and blood product administration 5.
• The use of high ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC) has been shown to improve survival in trauma patients, but the optimal ratio is still a topic of debate 5, 6.
• Damage control resuscitation (DCR), which involves the use of permissive hypotension, limited crystalloid administration, and early use of blood products, has been shown to improve outcomes in trauma patients with severe hemorrhage 6, 7.
• The use of tranexamic acid (TXA) has been shown to improve hemodynamic stability after trauma/hemorrhagic shock, but its effectiveness may depend on the type of resuscitation fluid used 8.
• Restrictive fluid resuscitation (RFR), which involves the use of limited amounts of crystalloid, has been shown to convey a survival benefit when used in combination with DCR 7.
• The choice of crystalloid fluid, such as normal saline (NS) or lactated Ringer's (LR), may not have a significant impact on outcomes, but NS may be a safe and cost-effective alternative to LR 9.

Key Considerations

• The goal of resuscitation is to maintain adequate blood pressure and perfusion of vital organs, while minimizing the risk of complications such as acidosis, coagulopathy, and multiple organ failure.
• The optimal resuscitation strategy may vary depending on the individual patient's needs and the specific circumstances of the trauma.
• A balanced approach that takes into account the latest evidence and guidelines is essential for optimizing outcomes in trauma patients.