Today we talk about the debate over whether to give vasopressors as part of a balanced resuscitation in early exsanguination…
Vasopressors for Traumatic Hemorrhage
Young, early trauma=high sympathomimetic tone
Older folks, extended shock, certain injury patterns = potentially inhibited sympathomimetic tone
Bleeding=cytokine release
Great Review Paper
Geographic Divide
Patterns of Usage
Is their own Catechol System Working?
What about abdominal injuries?
Splanchnic vasoconstriction
What About Peri-Anesthesia?
What About in Rural Settings?
Choice of Vasopressors
Vasopressin for Trauma
Sims et al. Paper
Meta-Analysis
What About Cirrhotics?
MAP Targets
Bare Minimum Normotension
All the way back in Podcast 13
MAP of 65?
MAP of 50?
RCT shows potential benefit from MAP goal of 50 mm HG [Morrison et al. 10.1097/TA.0b013e31820e77ea.] Less blood, best post-op mortality.
More papers:
- Kudo, Daisuke, Yoshitaro Yoshida, and Shigeki Kushimoto. “Permissive Hypotension/Hypotensive Resuscitation and Restricted/Controlled Resuscitation in Patients with Severe Trauma.” Journal of Intensive Care 5, no. 1 (January 20, 2017): 11. https://doi.org/10.1186/s40560-016-0202-z.
- Owattanapanich, Natthida, Kaweesak Chittawatanarat, Thoetphum Benyakorn, and Jatuporn Sirikun. “Risks and Benefits of Hypotensive Resuscitation in Patients with Traumatic Hemorrhagic Shock: A Meta-Analysis.” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 26, no. 1 (December 17, 2018): 107. https://doi.org/10.1186/s13049-018-0572-4.
- Tran, Alexandre, Jeffrey Yates, Aaron Lau, Jacinthe Lampron, and Maher Matar. “Permissive Hypotension versus Conventional Resuscitation Strategies in Adult Trauma Patients with Hemorrhagic Shock: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” The Journal of Trauma and Acute Care Surgery 84, no. 5 (May 2018): 802–8. https://doi.org/10.1097/TA.0000000000001816.
BTF Guidelines in TBI
MAP of 80?
Maintaining SBP at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg or above for patients 15 to 49 or over 70 years old may be considered to decrease mortality and improve outcomes.
Additional New Information
More on EMCrit
Not a ED/trauma doc so all my hemorrhage is medical hemorrhage, but you had a podcast with an anesthesiologist talking about hemorrhage resuscitation within the past year. He reported his practice of throwing on pulse-pressure variation measurement on the a-line to help guide whether the inevitable recurrence/ongoing hypotension in the hemorrhaging patient was more due to ongoing volume loss or developing vasoplegia and whether patient needed more product or pressor. Seemed like a very simple but nifty idea for guiding ongoing resuscitation. Don’t know that it’s necessarily better than feeling for warm/cold extremities and watching the gross pulse pressure trend,… Read more »
Hi Josh, That anesthesiologist is me. It works great if the patient is intubated. I use PPV to decide on vasopressors (vasopressin). I agree with almost everything Scott suggested. Couple of practical points: Calcium chloride 1-2 grams as god-given vasopressor before giving induction agent – ketamine in DSI manner. I don’t give epi unless the patient is nearing cardiac arrest, ETCO2 below 20 for the reasons of arrhythmias, severe tachycardia, additional vasoconstriction, and possibly worsening of coagulopathy due to SHINE (shock-induced endoteliopathy) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5299749/ If PPV is in the normal range and the patient is still hypotensive – the first step… Read more »
Great discussion Scott I have never been a vasopressor user in these settings, but based on your conversation, I had a question: you mention the roller coaster we are all used to when titrating in analgesics and waiting for the blood resuscitation to catch up. I wonder whether this is the exact role of vasopressors. To decrease the amplitude of the roller coaster by supplementing the patient’s endogenous catecholamines, which you are turning off, allowing for more rapid titration of analgesics. You lose some degree of feedback, but in the average doc’s hands, it might let us get our patients… Read more »
sure, it would eliminate the roller coaster, but in the exact opposite way we want. We want to eliminate the roller coaster by shedding vasopressor tone until we have a barely normal blood pressure with good peripheral perfusion–this is a resuscitated patient ready for the OR. Versus a patient to whom we have added even more vasoconstriction so their pressure looks great but their perfusion is trash. If you mean, using pressors as a bridge while titrating in sympatholytics, the problem wit that is that we lose BP as a marker for the need for additional product resuscitation.
I’m a believer in opioid (fentanyl) very gentle titration to improve microcirculation. Ideally, hemorrhage should be controlled at that point otherwise there is a risk of loosing sympathetic tone.
You may see those patine who would benefit a lot from this approach – somebody who has normal H/H, replenished circulating volume but very high lactate, this is your ideal opioid titration candidate.
I’m a paramedic and just presented on this at a conference earlier this year. The premise being is that blood products alone do not restore perfusion and the permissive hypotension strategy is only good for so long. Great episode!
I had a recent poly trauma that I was massive transfusing and used pressors on and had what appear to be favorable results.. this was actually right after I listened to this episode. Young-ish and generally healthy patient, stabilized initially w/product but bottomed out again. Patient was warm so I decided to use levophed while we transfused again. Able to ween off after second round of Xfusion, had to turn back on and weened off again after another Xfusion. Basically I maxed at .05/kg/min and if pressures went down I infused more product and tried to ween back down levo.… Read more »
My guess from a German point of view why the recommendations differ between early catecholamines or not: The vast majority of patients fall in the category which you said you would treat with early catecholamines: We have very few young gunshot or stab wound patients who come to us already exsanguinated. Most of them are old / multiple organ trauma / blunt trauma who early show “SIRS like” “cat. deficiency”. Most of the time they are considered “peri anesthesia” here: trauma resus happens in the OR, or seldomly, when they don’t need immediate surgery, in the SICU (where they are… Read more »
all of that makes sense, buddy!
Young poly trauma patients with high cytrokine release responded well with CRRT initiation..Any role in EARLY CRRT for patients with severe metabolic acidosis , not responding to vasopressors, massive transfusion
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