Way back in episode 197, I discussed the logistics of massive transfusion. Today, we go further on this topic with Roman Dudaryk, a trauma anesthesiologist. We have an amazing conversation on the nitty gritty of mass trans logistics.
Roman Dudaryk MD
Dr. Roman Dudaryk is the Professor of Anesthesiology and Director of Quality in the Department of Anesthesiology, Perioperative Medicine, and Pain Management at the University of Miami Miller School of Medicine.
Dr. Dudaryk has completed a Residency in Anesthesiology at Jackson Memorial Hospital where he served as chief resident. Additionally, he completed a Fellowship in Critical Care Medicine and Perioperative Echocardiography at Duke University. He is board certified in Anesthesiology, Critical Care Medicine, and Perioperative Transesophageal Echocardiography.
Dr. Dudaryk is the author of more than 50 peer-reviewed publications, original research manuscripts, invited editorials, review articles and book chapters. He also provides consulting and educational services to several medical device manufacturing companies. His personal research interests are trauma-induced coagulopathy, resuscitation, transfusion, viscoelastic monitoring, perioperative anticoagulation management and medical alarms. Dr. Dudaryk has published and presented numerous abstracts at national and international meetings. He currently lectures nationally on numerous topics related to the area of his interest.
Potassium Contents of Blood Products
Read the Trauma Issue of Anesth Analg
Additional New Information
More on EMCrit
Additional Resources
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
super informative. do you use ultrasound when you place subclavians now? if there is no pelvic or great vessel injury below subclavian area is there a problem with femoral access? do you use radial or femoral for arterial line?
We both place blind subclavians, aka the Line of Trauma–problem is as Roman mentioned, you need about 30 to get good. Femoral access is only a problem in IVC injury, pelvic trauma is irrelevant. All art lines in crashing patients should be placed in the femoral or axillary
Thank you. Agreed, suspected IVC or major liver injury should steer you away from femoral access. Pelvic injury is not a problem from the perspective of administering resuscitation but might be a practical challenge due to the need for pelvic binders or damage-controlled orthopedics later – it will just get in the way. Sublavians are placed blindly by experienced operators – usually attending or trauma surgery fellows. Femorals should be placed with US guidance to avoid technical misadventures that may lead to retroperitoneal bleeding and further complicate the fog of trauma. As for a-lines: in the resuscitation bay usually femoral… Read more »
Why blind subclavians? Why is it the fastest? Is it because in this context of sick trauma patient you are doing it non steril? Even experienced docs misses sometimes or the wire do not thread. Wouldn’t a non steril USG IJ be faster? And what about us, the «new generation» EM/ICU/Anesthesia docs who struggle to get a critical mass on the blind procedure? What should we do? Are the arguments for doing it blind in this context good enough that we should try and change our institutions to «allow» training in this procedure? In many institutions in Europe only cardiac… Read more »
I appreciate valid concerns. Certainly, other lines are valid options, even well working 14 or 16 G PIV may do the job, assuming it is monitored and pressure on the rapid infuser line is watched closely to detect any obstruction or mechanical problem. We stated that given all the options blind subclavian by an experienced operator is the line of choice for us in crashing or near arresting, trauma patients for many reasons. Because the vein is fixed to the clavicle it remains widely open, and does not require Trendelenburg position to increase cross-section; no problem with C-collar manipulations contrary… Read more »
Thank you for a comprehensive answer!
Great episode! I had the honor to train at Ryder trauma center by Dr Dudaryk amongst other amazing anesthesiologists. Practicing trauma anesthesia and critical care medicine in rural America now is a bit different than my days at Ryder, but I feel confident thanks to the strong training I had. I agree with the subclavian been the go-to trauma line, and IJs on the second place, but having 2 large PIVs shouldn’t be all that we actually need? at least to start the MTP, and even if there’s a need to start pressors, it shouldn’t be delayed waiting for a… Read more »
Adriana, I agree with your statement – a large bore (at least 16G), and functioning PIV is plenty to start MTP. It gives a flow rate close to 200ml/min, e.g. almost a unit of blood per minute. The caveat is they are less reliable and may blow out, so monitoring the site and pressure on the infuser is essential. If the infuser starts beeping due to high pressure – be concerned and make sure the site is good, check it with a manual flush. Additionally, Belmont infusers have a Y-piece that can be used for 2 sites, so even 2… Read more »
I have seen other issues using the Belmont bucket. It is easy to loose all track of what is in the bucket and what has gone into the patient. Of all the empty bags of product on the floor, how much volume of each product is in the patient and how much is still in the bucket? The bucket also encourages some providers to re-prime with crystalloid when it runs low or reaches empty.
Excellent points. I have seen a litter of crystalloid in the bucket for priming – because it’s so wide it gives a false impression of low volume. The major advantage of the bucket is the super high velocity of transfusion 400-500 ml/min when you can dump many units of products quickly without change of interruption – rapid clamping/unclamping and switching units on 3 spike Belmont filter is a skill. In reality, those cases are rare so the risk/benefit ratio favors staying away from the bucket in the ED/ICU/resus areas.
thank you so much for this fun episode! I am relatively new to the Belmont and recently had issues with the Belmont and io acces. scarce literature shows that pressure bag infusion might be better than the rapid infusor. Is this also your experience ? or is there a smart workaround?
thanks!
do you have a citation, Pauline?
not the best quality EBM but found 2
– Lairet et al. Intraosseous Pressure Infusion Comparison Using a Rapid Infusion Device and a Pressure Bag In a Swine Model Ann Emerg Med 2010;56(3):S26
– Auten et al.Comparison of Three IO Transfusion Strategies Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock . .
though the last one doesnt specify which machine they use.
If you want I can send pdfs
The first study was somehow inflating pressure bags to 600 mm Hg, so of course that would beat the 300 max of the Belmont. But our pressure bags do not go that high, and I’m not even sure how far you can overinflate beyond the gauge safely. Can’t find the 2nd paper in pubmed
Incredible episode guys. So much good information. I apologize if you all covered this in previous episodes, but I don’t think I heard you all talk about RICs in this one. My question is: Do you all commonly use RICs in the context of an MTP activation in the ED resus bay and if so when? Tons of potential nuance here, but the flow I imagine that would get the biggest bang for your buck would be: Confirm need for MTP Delegate team members to complete the following simultaneously: Place or confirm two points of large bore peripheral IV access… Read more »
Hey Cal,
I have mentioned RICs in many other episodes and I kind of have mixed feelings re: this device. If it goes in it is a joy–can’t beat the access. But even the smaller size is so large that it often blows the vein in all but the young men. I would love a 16 G RIC and I think it would be the ultimate trauma line for most cases.