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Review of Fluid Therapy in Acute Blood Loss

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Review of Fluid Therapy in Acute Blood Loss HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT Review of Fluid Therapy in Acute Blood Loss Michele L. Frazer, DVM, Diplomate ACVIM, ACVECC Permissive hypotension and increased use of plasma and fresh, warm, whole blood instead of crystalloid fluids may benefit equine patients with acute blood loss. Author’s address: Hagyard Equine Medical Institute, 4250 Iron Works Pike, Lexington, KY 40511; e-mail: [email protected]. © 2013 AAEP. 1. Introduction This eventually leads to organ dysfunction and car- Acute blood loss in the veterinary patient is an diovascular collapse. emergency that many practitioners must manage in Patients with blood loss can be placed into one of the field or hospital setting. Diagnosis may be ob- four categories as defined by the American College of 1 vious in cases of external blood loss, whereas inter- Surgeons. Category 1 is loss of Յ15% of blood nal blood loss may be more difficult to determine. volume. Transcapillary refill typically compen- Acute hemorrhage can occur into the peritoneal, sates for this loss and maintains blood volume and pleural, or pericardial cavities; reproductive tract; blood pressure. Category 2 is loss of 15% to 30% of gastrointestinal tract; guttural pouches; joints; and blood volume. Compensatory mechanisms such as muscle tissue. In the equine patient, common tachycardia and tachypnea occur, and sympathetic causes include trauma, rupture of a vessel in the vasoconstriction can typically maintain blood pres- reproductive tract in pre- or post-foaling mares, frac- sure. Category 3 is loss of 30% to 40% of blood tured ribs in foals, and inadequate hemostasis volume. Compensatory mechanisms can no longer during surgery. History, physical examination, ul- maintain blood pressure, and decompensated hypo- trasound examination, and blood work aid in diag- volemic shock occurs. Organ dysfunction, such as nosing acute hemorrhage as well as assessing the acute renal failure, may occur from decreased tissue severity and determining the cause. oxygenation. Decreased urine production and hy- In hemorrhage, the number of circulating red potension occur. Category 4 is loss of Ͼ40% of blood cells decreases, and the oxygen-carrying ca- blood volume. Patients in this category require im- pacity of the blood is compromised. Initially, phys- mediate emergency treatment, and changes in blood iological responses are able to compensate and pressure and perfusion may not be reversible. maintain blood pressure with transcapillary refill, The goal of treatment in patients with acute blood tachycardia, tachypnea, and systemic vasoconstric- loss is preventing hemorrhagic shock while also tion. When significant volume is lost, the body can no preventing further loss of blood. Two areas of longer compensate for the blood loss, and hemorrhagic controversy have occurred as to how best to accom- shock occurs. In this situation, adequate tissue plish this goal: fluid type and volume to be perfusion and oxygenation cannot be maintained. administered. NOTES 458 2013 ր Vol. 59 ր AAEP PROCEEDINGS HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT 2. Materials and Methods 4. Discussion A review of literature from the past 10 years describ- Different strategies are used to treat acute blood ing fluid resuscitation for acute blood loss in human loss in veterinary patients. Some clinicians limit medicine was undertaken. Current trends in fluid intravenous fluid therapy in an attempt to maintain choice and volume of fluid administered were low blood pressure and limit further hemorrhage. reviewed. The risk of limiting fluid therapy is hypovolemic shock and subsequent cardiovascular collapse. 3. Results Without appropriate fluid volume, organs do not In human medicine, a strategy has been developed receive adequate perfusion and oxygenation. In op- called Damage Control Resuscitation (DCR) to re- position, some clinicians advocate more liberal use suscitate patients with acute hemorrhage.2,3 The of crystalloid and colloid fluids to maintain blood goal of DCR is early prevention and/or treatment of pressure in a range closer to normal to preserve the lethal triad. The lethal triad consists of coagu- organ perfusion and prevent hypovolemic shock. lopathies, hypothermia, and acidosis.3 Metabolic The risk with this method is that further hemor- acidosis occurs from hypoperfusion leading to organ/ rhage may occur. tissue damage from decreased oxygenation and a Veterinarians also vary in what fluid should be switch to anaerobic metabolism. Hypothermia re- used in resuscitation. Crystalloid fluids are typi- sults from hypoperfusion and, if used in treatment, cally inexpensive, easy to administer, and readily the use of cold resuscitation fluids. Coagulopathies available to most practitioners. However, the primarily occur from hypoperfusion and tissue majority of the fluid rapidly leaves the vascular trauma. Other factors including loss of procoagu- compartment and moves to the interstitial space. lant proteases, dilution of blood from fluid resusci- Colloid fluids are more expensive and require spe- tation, and organ dysfunction from acidosis and cialized equipment to administer. Fresh, whole hypothermia also potentiate coagulopathies.4–6 blood requires the presence of a donor and ideally, a One of the key points in the DCR resuscitation laboratory to perform a cross-match. Plasma re- plan is permissive hypotension. A minimum vol- quires refrigeration for storage. Both require spe- ume of intravascular fluid replacement is adminis- cialized IV lines with a filter designed for tered at a rate to maintain mean arterial blood administration of blood products. Anaphylactic re- pressure at 50 mm Hg and systolic blood pressure at actions may occur with either. Hydroxyethyl 80 mm Hg. These pressures are considered suffi- starch, a synthetic colloid, does not require refriger- cient to maintain organ perfusion without potenti- ation or specialized equipment to administer, but it ating hemorrhage. Proponents of DCR cited a 40% has been associated with coagulopathies. Also, col- survival rate in DCR-resuscitated patients versus a loids may increase the blood pressure more than 16% survival rate in patients not undergoing DCR 7–10 desired and may potentiate further bleeding. resuscitation strategies. DCR is now the stan- Extrapolating data and strategies from human dard of care for resuscitating patients with blood 7 medicine and applying it to veterinary medicine may loss in human medicine. The DCR strategy has assist the veterinarian in establishing a treatment emerged over the past decade and is in opposition to plan for resuscitative fluids in acute hemorrhage the strategy used during the past century, when cases. Application of DCR strategy to veterinary rapid volume expansion with crystalloid fluids was medicine will guide the practitioner in choice of re- used in cases of hemorrhagic shock. suscitative fluid in hemorrhagic shock. Plasma Permissive hypotension should not be confused with prolonged hypoperfusion. Prolonged hypoper- and potentially warm whole blood should be the fusion and failure to maintain blood pressure at initial resuscitation fluid. Plasma provides addi- DCR-recommended levels results in decreased per- tional clotting factors. Warm blood is used to pre- fusion to vital organs and tissues leading to meta- vent hypothermia because the coagulation cascade bolic acidosis, hypothermia, and coagulopathies. is less effective at lower body temperatures. Fresh, Coagulopathies are associated with increased mor- whole blood is preferred over packed red blood cells. tality in patients with hemorrhagic shock.11–13 Interestingly, this practice is already routinely per- The second key point in DCR resuscitation is the formed in equine medicine because a blood bank type of fluid chosen for initial resuscitation. The with packed red cells from equids is not available. DCR strategy recommends the use of plasma as the DCR protocol recommends minimal administra- initial resuscitation fluid. This early use of plasma tion of crystalloid fluids because they dilute coagu- aids in prevention of a coagulopathy, one component lation factors and may increase coagulopathies. of the lethal triad.14 Human studies claim a 46% However, in the equine patient, financial con- reduction in mortality rate when plasma was used straints and availability of colloids may prevent ad- in equal parts with whole blood as opposed to the use ministering the volume of plasma and whole blood of more blood than plasma.14 Also, fresh, warm, needed to maintain mean arterial blood pressure at whole blood has been advocated over packed red 50 mm Mg. Crystalloid fluids, therefore, are re- blood cells.7,15,16 quired in these cases. AAEP PROCEEDINGS ր Vol. 59 ր 2013 459 HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT Historically, hemoglobin and hematocrit levels blood to equine patients with acute hemorrhage may have been utilized to determine when blood trans- assist the veterinary practitioner in successful treat- fusions should be administered. However, these ment of these cases. Limiting factors with this clinical parameters are not reliable transfusion trig- strategy are having the appropriate equipment to gers because they are unreliable indicators of blood monitor blood pressure and having access to plasma loss severity. In acute blood loss, red blood cells or whole blood. However, physical examination and plasma are both lost; therefore hematocrit and and blood work parameters may compensate for lack hemoglobin do not change until transcapillary refill of equipment. The
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