Massive Transfusion and Control of Hemorrhage in the Trauma Patient
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Massive Transfusion and Control of Hemorrhage in the Trauma Patient N A L T R A I O U T M A A N R C E A T R N E I I Based on Special ITACCS Seminar Panels. The International Trauma Anesthesia and Critical Care Society (ITACCS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) for physicians. This CME activity was planned and produced in accordance with the ACCME Essentials. ITACCS designates this CME activity for 15 credit hours in Category 1 of the Physicians Recognition Award of the American Medical Association. I CME QUESTIONS INCLUDED JANUARY 2003 LEARNING OBJECTIVES OF THE MONOGRAPH Chapter 6 Atraumatic blood salvage and autotransfusion in trauma and surgery .................................. Page 17 Sherwin V. Kevy, MD, and Robert Brustowicz, MD, Trans- After completion of this activity, the participant will be able to: fusion Service, Children’s Hospital Department of Anes- thesia, Harvard Medical School, Boston, Massachusetts 1. Evaluate the etiology and pathophysiology of traumatic shock. 2. Describe the management of massive transfusion in the trauma patient. Section III: Transfusion: Clinical Practice 3. Discuss the clinical indications and problems related to the use of blood, blood components, hemostatic agents, oxygen-carrying vol- Chapter 7 Current practices in blood and blood ume expanders, and venous thromboembolism prophylaxis. component therapy ....................................... Page 18 Charles E. Smith, MD, FRCPC, Department of Anesthesi- EDITORS ology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio Charles E. Smith, MD, FRCPC, Professor of Anesthesiology, Chapter 8 Immunomodulatory effects of transfusion .. Page 22 MetroHealth Medical Center, Case Western Reserve University School David T. Porembka, Do, FCCM, FCCP, Associate Professor of Medicine, Cleveland, Ohio; Chair, ITACCS Special Equipment/Tech- of Anesthesia and Surgery, Associate Director of Surgical niques Committee Intensive Care, University of Cincinnati Medical Center, Cincinnati, Ohio Andrew D. Rosenberg, MD, Chairman, Department of Anesthesi- ology, Hospital for Joint Diseases Orthopaedic Institute, Associate Pro- Chapter 9 Blood transfusions ........................................ Page 27 fessor of Clinical Anesthesiology, New York University School of Medi- Andrew D. Rosenberg, MD, Department of Anesthesiol- cine, New York, New York ogy, Hospital for Joint Diseases/Orthopaedic Institute, New York, New York Christopher M. Grande, MD, MPH, Lecturer, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Chapter 10 Vascular access in trauma: options, risks, Hospital, Harvard Medical School, Boston, Massachusetts; Professor, benefits, complications ................................. Page 28 Department of Anesthesiology, State University of New York, Buffalo, Maureen Nash Sweeney, MD, Attending Anesthesiologist, Buffalo, New York; Professor of Anesthesiology, West Virginia University Department of Anesthesiology, Department of Veterans School of Medicine, Morgantown, West Virginia; Executive Director, Affairs Medical Center, New York, New York International Trauma Anesthesia and Critical Care Society (ITACCS), World Headquarters Baltimore, Maryland Chapter 11 Principles of fluid warming .......................... Page 30 Charles E. Smith, MD, Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve Uni- CONTENTS AND CONTRIBUTORS versity, Cleveland, Ohio Chapter 12 Management of massive hemorrhage and Section I: Etiology and Pathophysiology transfusion in trauma ................................... Page 34 Chapter 1 Trauma, a disease of bleeding......................... Page 3 Georges Desjardins, MD, FRCPC, Division of Trauma Anes- Thomas M. Scalea, MD, Physician-in-Chief, Professor of thesia and Critical Care, Ryder Trauma Center, University Surgery, R Adams Cowley Shock Trauma Center, Baltimore, of Miami/Jackson Memorial Medical Center, Miami, Florida Maryland Chapter 13 Rapid infusion and point-of-care chemistry testing monitoring in massive transfusion: Chapter 2 Pathophysiology of traumatic shock .............. Page 5 avoiding common pitfalls ............................. Page 38 Richard P. Dutton, MD, Associate Director, Division of Jeffrey R. Jernigan, MD, and John G. D’Alessio, MD, De- Anesthesiology, R Adams Cowley Shock Trauma Center, partment of Anesthesiology, Elvis Presley Memorial Trauma Baltimore, Maryland Center, Memphis, Tennessee Section II: Therapeutic Strategies Section IV: New Horizons in Synthetic Blood Substitutes Chapter 3 Surgical perspectives to control Chapter 14 Hemoglobin-based oxygen-carrying bleeding in trauma .......................................... Page 7 solutions and hemorrhagic shock ............... Page 40 Brian R. Plaisier, MD, Department of Surgery, Bronson Colin F. Mackenzie, MB, ChB, FRCA, FCCM, Director, Methodist Hospital, Kalamazoo, Michigan National Study Center for Trauma and Emergency Medi- cal Systems, University of Maryland School of Medicine, Chapter 4 Hemostatic drugs in trauma and Baltimore, Maryland orthopaedic practice ..................................... Page 11 David Royston, MB, FRCA, Consultant Anaesthetist, Royal Chapter 15 Hemoglobin therapeutics, blood substitutes, Brompton and Harefield NHS Trust, Harefield, Middlesex, and high-volume blood loss .......................... Page 44 United Kingdom Armin Schubert, MD, MBA, Chairman, Department of Gen- eral Anesthesia, Cleveland Clinic Foundation, Cleveland, Ohio Chapter 5 Antithrombotics in Trauma Care: Benefits and Pitfalls ...................................... Page 14 CME Questions .................................................................. Page 48 John K. Stene, MD, PhD, Past President, ITACCS, Associate Professor of Anesthesia and Director of Trauma Anesthesia, The drug and dosage information presented in this publication is Milton S. Hershey Medical Center, Hershey, Pennsylvania believed to be accurate. However, the reader is urged to consult the full prescribing information on any product mentioned in this publication for recommended dosage, indications, contraindications, warnings, precautions, and adverse effects. This is particularly important for drugs that are new or prescribed infrequently. 2 Massive Transfusion and Control of Hemorrhage in the Trauma Patient Massive Transfusion and Control of Hemorrhage in the Trauma Patient fluids, endpoints of fluid and blood resuscita- potensive versus normotensive resuscitation, Introduction tion, complications of transfusion therapy, and the benefits of point-of-care testing, and the Priorities in trauma patient management clinical strategies to reduce complications. use of guidelines (in conjunction with the are to ensure adequate ventilation and oxygen- The section on “Transfusion: Clinical Prac- blood bank) for managing trauma patients who ation, control hemorrhage, and restore tissue tice” begins with a discussion on the immuno- require “rapid infusion.” perfusion to vital organs. The most familiar logic consequences of transfusions and con- In the final section on “New Horizons in means to control hemorrhage are surgical liga- cludes that allogeneic transfusions have a dy- Synthetic Blood Substitutes,” Dr. Mackenzie tures and clips. Other means include namic immunomodulatory effect on the recipi- reviews the complex issues surrounding the transcatheter embolization, appropriate blood ent and that leukocytes are the chief mediator use of hemoglobin solutions and hemorrhagic component therapy, maintenance of normo- of these effects. Dr. Rosenberg reviews the sci- shock. He states that, although many of the thermia, and pharmacologic agents. Finally, entific literature and his own personal experi- problems associated with oxygen-carrying so- attention must also be directed toward treat- ence with the concept of “decreasing the lutions have been overcome, there is a paucity ment of the hypercoaguable state that follows amount of blood transfused to trauma pa- of published data concerning the use of oxy- major traumatic injury and can lead to deep tients” in light of transfusion-related immuno- gen-carrying solutions in humans with hem- venous thrombosis and pulmonary embolism. suppression and other risks. Dr. Sweeney orrhagic shock. Dr. Schubert concludes the The management of massive transfusion evaluates the options, risks, and potential com- monograph by examining the potential clini- and control of hemorrhage in the trauma pa- plications of obtaining vascular access in cal uses and effectiveness of hemoglobin-based tient were discussed during two special trauma, illustrating the different approaches oxygen carriers and perfluorocarbons. The ITACCS seminars. The 15 reports in this in pediatric and adult trauma patients. The long shelf life, long circulation half-life, and monograph summarize the state-of-the art principles of warming IV fluid and blood are good oxygen-carrying capacity and tissue oxy- knowledge and clinical practice issues regard- reviewed by Dr. Smith, with special emphasis gen delivery make these compounds particu- ing surgical and nonsurgical management of on the thermal stress of infusing cold or inad- larly attractive in patients with high blood loss, massive transfusion and control of hemor- equately warmed fluids, and the safety and ef- i.e., trauma patients. In his manuscript, Dr. rhage in the injured patient. ficacy of fluid warmers and rapid infusion de- Schubert evaluates the different hemoglobin In