Case presentation on HEMOTHERAPY IN SHOCK- hypovolemia and hemorrhagic shock

damage control resuscitation
plasma expanders
hemorrhagic shock
hypovolemic shock
transfusion in shock
blood in shock
hemotherapy in shock
massive transfusion
hypotension
crystalloids
colloids
coagulopathy
hypothermia
acidosis
infusion therapy in shock
hemoglobin based oxygen carriers
prbc ffp platelets transfusion in shock
DCR

1. HEMOTHERAPY IN SHOCK Presenter- Dr. Shiny Moderator- Dr. Nidhi Bansal

2. INTRODUCTION Transfusion support is vital for a patient of trauma with hemorrhagic shock. The transfusion of the right component to the right patient in the right quantity and at the right time has been the main focus of attention for critical care doctors. Although blood is the ideal resuscitation agent from a physiological perspective, there are limitations to its use.

3. CASE A 57-year-old man was admitted to our ED with right massive  hemothorax   The patient had undergone needle biopsy of the  pleura  to examine bilateral  pleural effusion  of uncommon cause. Shortly after his arrival at our hospital, cardiac arrest occurred, and the patient needed ALS. We performed right  thoracotomy  and confirmed a bleeding point from right dorsal 5th  I/C artery . At surgery, his hemoglobin level was 4.6 g/dL, and his  fibrinogen  level was 83 mg/dL;  blood gas tests  showed a pH of 7.04 and a lactate level of 17.4 mmol/L. In addition, body temperature was 32.1 °C;

4. MANAGEMENT He already had all the components of the trauma deadly triad. A bolus of 2L crystalloid solution was infused. Massive transfusion protocol was established and 4 units of FFP, 1 unit of apheresis platelets and 4 red cells were transfused alongwith which damage control surgery was initiated. The bleeding site was closed with sutures, and the bleeding was stopped. The patient was saved and successfully managed under intensive care therapy.

5. DISCUSSION Initial hemorrhagic shock resuscitation begins with the administration of IV fluids, followed by transfusion of blood products at a 1:1:1 ratio.  When the etiology of hypovolemic shock has been determined, blood or fluid loss replacement should be carried out as soon as possible to minimize tissue ischemia. For patients presenting with hypovolemic shock, it is important to differentiate between hemorrhagic versus non-hemorrhagic hypovolemic shock. In terms of hemorrhagic shock resuscitation, using blood products over crystalloid resuscitation resulted in improved outcomes.

6. Infusion Therapy- Hypovolemic Shock Use crystalloids in appropriate volume, to prevent fluid overload- Despite decades of liberal use treating trauma patients, it is now known that infusing large volumes of crystalloid as a replacement for lost blood worsens the “vicious cycle of coagulopathy” resulting from hypoxia, acidosis, and hypothermia that was originally described 35 years ago. Intravenous fluids are known to dilute clotting factors, cool patients, and create acidosis.

7. 3 Types of Fluids 1. Crystalloids Lactated Ringer's solution is the most widely available and frequently used balanced salt solution. Crystalloid is the first fluid of choice for resuscitation. Immediately administer 2 L of isotonic sodium chloride solution or lactated Ringer’s solution in response to shock from blood loss. 3 L of fluid need to be administered to raise the intravascular volume by 1 L.

8. 2. Colloids- Several colloid solutions were studied in clinical practice including human albumin, hydroxyl ethyl starch (HES), and dextran colloids restore volume in a 1:1 ratio but  it has been associated with the induction of coagulopathy.  3. Hypertonic saline (5 ml/kg NaCl 7.5%)- In patients with hemorrhagic shock, hypertonic saline has the theoretical benefit of increasing intravascular volume with only small amounts of fluid.

9. HEMOTHERAPY- SHOCK Balanced (1:1:1) Resuscitation- PRBCs should be transfused if the patient remains unstable after 2000 mL of crystalloid resuscitation. For acute situations, O-negative noncrossmatched blood should be administered. 

10. Haemorrhagic Shock Hemotherapy Before 1995, aggressive resuscitation using crystalloid and RBCs was the standard of care in civilian hospitals. In the late 1990s, trauma surgeons started to recognize the potential deleterious effects of too much crystalloid, including increased risk of acute respiratory distress syndrome, multiple-organ failure, and abdominal compartment syndrome.

11. Gradually, and after new data became available from the military experience supporting combat casualties in the Iraq and Afghanistan wars, a new approach to hemorrhagic shock, damage control resuscitation , was adopted. This approach included the early transfusion of plasma and platelets in addition to RBCs while minimizing crystalloid use . An increased ratio of plasma to RBCs or platelets to RBCs was independently associated with decreased 6-hour mortality.

12. Hemotherapy- Hemorrhagic Shock Whole blood- With the advent of blood component therapy, the use of whole blood as a resuscitation fluid has become obsolete. It may only be suggested if blood loss is >40%. Whole blood is deficient in clotting factors and has high levels of potassium, ammonia, and hydrogen ions. Although it provides volume expansion along with increased oxygen-carrying capacity, there can be volume overload before the needed components are replenished.

13. Packed red blood cells Since the central pathophysiology of hemorrhagic shock is failure of oxygen delivery , timely administration of red blood cells is the most important component of resuscitation. Blood loss greater than 25% to 30% usually requires transfusion of packed red blood cells in addition to crystalloids.

14. Fresh frozen plasma (FFP) utilized for its clotting factor content in trauma resuscitation. Administration of FFP should be guided by serial measurement of clotting times, fibrinogen levels, prothrombin time (PT), and (APTT).

15. Platelets The decision to transfuse platelets in shock should be based on the extent of the thrombocytopenia , the presence or absence of active bleeding , and the need for surgical intervention. 

16. Recombinant erythropoietin Hemorrhagic shock leads to suppression of erythrocyte production due to the effect of cytokines released as a part of the systemic inflammatory response. High levels of erythropoietin achieved by recombinant erythropoietin administration have established a robust erythrocyte response in the seriously injured patient.

17. Hemoglobin-based oxygen carriers HBOCs represent an attempt to create a resuscitative fluid with the O2-carrying capacity of red blood cells but without the need for cross-matching or the potential for viral transmission. These solutions are either human or bovine in origin and consist of Hb dimers or tetramers. They have shorter half-lives than red blood cells (hours to days). Studies have shown promising results, demonstrating that HBOCs are capable of replacing all or part of the transfusion requirements in surgerirs and shock.

18. RECENT ADVANCES

19. DCR Damage control resuscitation (DCR), the strategic approach to the trauma patient who presents in extremis, consists of balanced resuscitation, hemostatic resuscitation, and prevention of acidosis, hypothermia, and hypocalcemia. In balanced resuscitation, fluid administration is restricted and hypotension is allowed until definitive hemostatic measures begin. The administration of blood products consisting of fresh frozen plasma, packed red blood cells, and platelets, the ratio of which resembles whole blood, is recommended early in the resuscitation.

20. Intravenous Fluid Versus Blood The practice of crystalloid fluid resuscitation was supported by 1960’s data which suggested a hemorrhage was associated with a loss of isotonic fluid in the extracellular space. This fluid deficit could be readily replaced with isotonic crystalloid. However, there is a growing body of literature highlighting the harms of crystalloid fluids in shock states, and, specifically, in major trauma. Crystalloid fluid promotes acidosis, dilutes coagulation factors, and disturbs inflammatory mediators. The harms of crystalloid resuscitation in trauma patients are well documented. 

21. REFERENCES Resuscitation for Hypovolemic Shock Kyle J. Kalkwarf , Bryan A. Cotton Transfusion protocol in trauma Paramjit Kaur ,  Sabita Basu , 1   Gagandeep Kaur , 1  and  Ravneet Kaur 1 AABB Technical Manual https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141982/ THANKYOU